Continuation Electroconvulsive Therapy Research Articles

Electroconvulsive therapy: 80 years of use in psychiatry

Electroconvulsive therapy (ECT) is the oldest among the early biological treatments introduced in psychiatry, and the only one still in use. In this paper we attempt a brief presentation of ECT usage over the last 80 years, since it was originally introduced. It is a safe, well-tolerated, and highly effective treatment option for major psychiatric disorders, such as mood disorders and schizophrenia, especially when there is an acute exacerbation of psychotic symptoms or if catatonic symptoms are prominent. ECT has also been used successfully for the treatment of Parkinson's disease, delirium, neuroleptic malignant syndrome, autism and agitation and depression in demented patients. There are no absolute contraindications. However, it is considered a high risk procedure for patients with increased intracranial pressure, recent myocardial infarction, recent cerebral hemorrhage or stroke, vascular aneurysm, retinal detachment and pheocromocytoma. Modern genetic and neuroimaging techniques have helped clarify possible mechanisms of action of ECT, but much remains unknown. Improvement of this method through a number of technical advancements has contributed in the reduction of side effects. Thus, modified ECT is currently considered as an effective and safe form of treatment even in vulnerable populations such as the geriatric patients, the adolescents and the pregnant patients. The mortality rate is very low, comparable to that of a minor anesthetic procedure. The most common adverse events are headache, nausea, myalgias and postictal delirium while the most severe are the cardiovascular side effects. Of note, the cognitive side effects especially amnesia, although transient, has been the focus of skepticism against the treatment. Major psychiatric disorders are chronic, recurring disorders. The relapse rate after a successful course of ECT without any intervention is extremely high. Pharmacotherapy or continuation ECT reduces equally the relapse rate up to 40%. Continuation and maintenance ECT, in combination with pharmacotherapy, have been successfully used in preventing relapse and recurrence. Gradual tapering off acute ECT treatments and individualized continuation and maintenance ECT treatments based on the needs of each patient seems the optimum clinical practice. Conclusively, despite impressive new developments in pharmacotherapy and in biological non pharmacological treatments ECT remains a valuable, irreplaceable treatment option for debilitating, resistant major psychiatric disorders.

Clinical outcome after stop continuation and maintenance electroconvulsive therapy: A longitudinal retrospective study

Clinical outcome after stop continuation and maintenance electroconvulsive therapy: A longitudinal retrospective study

Determinants of relapse after electroconvulsive therapy in depressed patients

Maintaining remission after successful acute treatment remains a challenge in the use of electroconvulsive therapy (ECT). For this purpose, the concept of gradually tapered continuation ECT (C-ECT) has been increasingly propagated. The present study is aimed at identifying factors that contribute to relapse after ECT in depressed patients. After successful acute treatment of a depressive episode with ECT, all patients were offered a fixed schedule of C-ECT. The number of C-ECT sessions varied in this naturalistic setting depending on compliance. All patients with follow-up data of at least 6 months were included (n = 82). Survival analyses with time to relapse as dependent variable were used to estimate the risk of relapse. 34.1 % of the patients relapsed within 6 months. Factors associated with a decreased relapse rate were: 1. C-ECT treatment, especially within the first three month; 2. higher mean charge during I-ECT; 3. switch from unilateral to bilateral electrode placement during I-ECT, and 4. male sex. However, the sensitivity analyses suggest that the influence of sex on relapse was limited to the first three months of the continuation phase. As expected, C-ECT reduced relapse rates, especially when performed early after I-ECT. Besides, increased charge and a change of electrode placement from unilateral to bilateral during the index series were associated with a lower risk of relapse. Compared to men, there was a higher rate of relapse in women.

Electroconvulsive therapy in the continuation and maintenance treatment of depression: Systematic review and meta-analyses.

Acute course of electroconvulsive therapy is effective in inducing remission from depression, but recurrence rate is unacceptably high following termination of electroconvulsive therapy despite continued pharmacotherapy. Continuation electroconvulsive therapy and maintenance electroconvulsive therapy have been studied for their efficacy in preventing relapse and recurrence of depression. The purpose of this meta-analysis was to examine the efficacy of continuation electroconvulsive therapy and maintenance electroconvulsive therapy in preventing relapse and recurrence of depression in comparison to antidepressant pharmacotherapy alone. We searched MEDLINE, Embase, PsycINFO, clinicaltrials.gov and Cochrane register of controlled trials from the database inception to December 2016 without restriction on language or publication status for randomized trials of continuation electroconvulsive therapy and maintenance electroconvulsive therapy. Two independent Cochrane reviewers extracted the data in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews and meta-analyses. The risk of bias was assessed using four domains of the Cochrane Collaboration Risk of Bias Tool. Outcomes were pooled using random effect model. The primary outcome was relapse or recurrence of depression. Five studies involving 436 patients were included in the meta-analysis. Analysis of the pooled data showed that continuation electroconvulsive therapy and maintenance electroconvulsive therapy, both with pharmacotherapy, were associated with significantly fewer relapses and recurrences than pharmacotherapy alone at 6 months and 1 year after a successful acute course of electroconvulsive therapy (risk ratio = 0.64, 95% confidence interval = [0.41, 0.98], p = 0.04, risk ratio = 0.46, 95% confidence interval = [0.21, 0.98], p = 0.05, respectively). There was insufficient data to perform a meta-analysis of stand-alone continuation electroconvulsive therapy or maintenance electroconvulsive therapy beyond 1 year. There are only a few randomized trials of continuation electroconvulsive therapy and maintenance electroconvulsive therapy. The preliminary and limited evidence suggests the modest efficacy of continuation electroconvulsive therapy and maintenance electroconvulsive therapy with concomitant pharmacotherapy in preventing relapse and recurrence of depressive episodes for 1 year after the remission of index episode with the acute course of electroconvulsive therapy.

The PRIDE Study and the Conduct of Electroconvulsive Therapy: Questions Answered and Unanswered.

The recently published PRIDE study (prolonging remission in the depressed elderly) constitutes an important contribution to electroconvulsive therapy (ECT) technique, from the standpoint of both the index course to treat depressive symptoms and the post-remission continuation period to prevent relapse. This study was probably the last large, National Institute of Mental Health-funded, multisite ECT technical study for some time to come, so extracting clinically relevant recommendations is worthwhile. In this commentary, the author discusses evidence from this trial relevant to several important clinical index and continuation ECT technical issues and elaborates several unanswered questions deserving further consideration.

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

760. Continuation ECT for Relapse Prevention in Depressed Elderly. Results From the Pride Study

760. Continuation ECT for Relapse Prevention in Depressed Elderly. Results From the Pride Study

Current status of electroconvulsive therapy for mood disorders: a clinical review

Electroconvulsive therapy (ECT) is an effective treatment for mood disorders and a viable treatment option especially when urgency of clinical situation requires a prompt treatment response. After acute series of...

Finally, Evidence for Continuation Electroconvulsive Therapy in Major Depressive Disorder.

Finally, Evidence for Continuation Electroconvulsive Therapy in Major Depressive Disorder.

Continuation ECT with medication improves outcomes in geriatric depression

Continuation electroconvulsive therapy (ECT) plus medication in elderly patients who had experienced a successful course of ECT resulted in more improvement in depressive symptoms than medication alone, according to results of the second phase of the Prolonging Remission in Depressed Elderly (PRIDE) study. A flexible ECT protocol in Phase 2 involved four treatments over one month and additional treatments as needed. Phase 2 results were published online July 15 in the American Journal of Psychiatry.

A Novel Strategy for Continuation ECT in Geriatric Depression: Phase 2 of the PRIDE Study.

The randomized phase (phase 2) of the Prolonging Remission in Depressed Elderly (PRIDE) study evaluated the efficacy and tolerability of continuation ECT plus medication compared with medication alone in depressed geriatric patients after a successful course of ECT (phase 1). PRIDE was a two-phase multisite study. Phase 1 was an acute course of right unilateral ultrabrief pulse ECT, augmented with venlafaxine. Phase 2 compared two randomized treatment arms: a medication only arm (venlafaxine plus lithium, over 24 weeks) and an ECT plus medication arm (four continuation ECT treatments over 1 month, plus additional ECT as needed, using the Symptom-Titrated, Algorithm-Based Longitudinal ECT [STABLE] algorithm, while continuing venlafaxine plus lithium). The intent-to-treat sample comprised 120 remitters from phase 1. The primary efficacy outcome measure was score on the 24-item Hamilton Depression Rating Scale (HAM-D), and the secondary efficacy outcome was score on the Clinical Global Impressions severity scale (CGI-S). Tolerability as measured by neurocognitive performance (reported elsewhere) was assessed using an extensive test battery; global cognitive functioning as assessed by the Mini-Mental State Examination (MMSE) is reported here. Longitudinal mixed-effects repeated-measures modeling was used to compare ECT plus medication and medication alone for efficacy and global cognitive function outcomes. At 24 weeks, the ECT plus medication group had statistically significantly lower HAM-D scores than the medication only group. The difference in adjusted mean HAM-D scores at study end was 4.2 (95% CI=1.6, 6.9). Significantly more patients in the ECT plus medication group were rated "not ill at all" on the CGI-S compared with the medication only group. There was no statistically significant difference between groups in MMSE score. Additional ECT after remission (here operationalized as four continuation ECT treatments followed by further ECT only as needed) was beneficial in sustaining mood improvement for most patients.

ECT Said to Be Valid Alternative For Elderly Patients With Depression

ECT Said to Be Valid Alternative For Elderly Patients With Depression

The use of electroconvulsive therapy (ECT) in the Czech Republic

AimThe aim of this study was to monitor the use of electroconvulsive therapy (ECT) in the Czech Republic for the purpose of harmonizing national practice.MethodA 13-item questionnaire was sent to all Czech inpatient psychiatric facilities. This questionnaire assessed technical background of ECT, indications for the treatment, procedure in detail, way of documentation and monitoring of side effects.ResultsECT is used 23 centers (10 psychiatric hospitals, 5 university psychiatric departments and 8 psychiatric wards) across the Czech Republic. There is no special legal act regulating the use of ECT in the CR, but there are guidelines issued by the Czech Psychiatric Society available. All centers use instruments delivering brief pulse stimuli. All patients have to be indicated for this treatment and have to sign inform consent form/excluding situation when patient's life is endangered/. Somatic state is assessed/EKG, blood tests, eye check-up regularly and other examinations in individual cases/. Thiopenthal and succinylcholine are used most often for anesthesia and myorelaxation. Bitemporal electrode placement is the preferred option in all centers. The ECT is provided 2–4 times a week in special ECT rooms in the presence of staff team/psychiatrist, anesthetist, psychiatric and anesthesiological nurses/. Continuation ECT and outpatient ECT is not used. The procedure including side effects is documented in individual patient's documentation, but summarizing documentation is conducted only in some centers.ConclusionECT is widely used in the Czech Republic. Procedures in all centers follow national guidelines. There is need to improve documentation system to harmonize national practice.Disclosure of interestThe authors have not supplied their declaration of competing interest.

ECT-treatment in Western Norway; first data from the Regional register of neurostimulation treatment

IntroductionElectroconvulsive therapy (ECT) is one of the most polarizing treatments in medicine. Although the treatment effect is well documented in clinical studies, there is a lack of data regarding patients treated in an ordinary clinical setting. In 2013, we established a regional register of neurostimulation treatment in Western Norway.ObjectivesTo describe the use of ECT at the Haukeland university hospital in Bergen.MethodsPatients treated with ECT between June 2013 and June 2015 were included in the register.ResultsOne hundred and forty-seven patients received ECT during the 2 years period. The mean age was 58.4 years (22–91 years), 67% were female. Half of the patients (49.7%) had been treated with ECT previously. Indication for treatment was depression in 137 patients (93.2%), of which 29 (19.7%) were moderately, and 69 patients (46.9%) severely depressed, and additional 37 patients (25.2%) presented with severe depression with psychotic features. All but two patients were treated with right unilateral electrode placement, with a mean of 9.7 (3–22) treatments.The mean MADRS before treatment was 34.2 (4–56) and after treatment 11.9 (0–39). One hundred and ten patients (74.8%) responded to treatment; of which 89 (60.5%) remitted (response defined as a 50% or greater decrease from MADRS baseline score, remission defined as MADRS ≤ 12). Twenty patients (13%) continued with continuation or maintenance ECT after the index series.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Posterior vitreous detachment and electroconvulsive therapy: Insights from a case

A case of bilateral posterior vitreous detachment after electroconvulsive therapy (ECT) has been reported previously in the literature. There is not enough evidence about ocular side effects of this treatment. The literature supports a slight increase in intraocular pressure (IOP), although no ocular complications have been reported in normal, glaucomatous or postsurgical eyes. In this case report, we describe a 73-year-old female patient suffering a recurrent depressive disorder, who was admitted to acute psychiatric unit because a treatment-resistant major depressive episode (after an adequate trial of antidepressant drugs and transcranial magnetic stimulation) and clinical suspicion of visual delusions by her reference psychiatrist. The nonpsychiatric history consisted of hypertension, glaucoma and ulcerative colitis in treatment with azathioprine and mesalazine. After a careful examination in the emergency room, we consulted to ophthalmologist because miodesopsias and glaucoma history. The IOP was normal, but a bilateral posterior vitreous detachment (PVD) was identified. Because this entity is not an absolute contraindication for ECT, and there is scarce evidence, we informed the patient and her family. After that, and through informed consent, we decided to undergo ECT. After fourteen sessions, the patient could be discharged because significant clinical benefit and no ocular complications. Outpatient continuation ECT was indicated.ConclusionsECT can be a safe treatment choice in cases of PVD.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Practice of Acute and Maintenance Electroconvulsive Therapy in the Psychiatric Clinic of a University Hospital from Turkey: between 2007 and 2013.

ObjectiveElectroconvulsive therapy (ECT) can be given as the form of acute, continuation or maintenance ECT according to the process of administration. We report our 7 years’ observation with acute and maintenance ECT in a university hospital in Turkey.MethodsThe medical records of the hospitalized patients treated with acute or maintenance ECT between the years 2007 and 2013 was retrospectively analyzed. The sociodemographic characteristics, diagnosis, data of ECT and the co-administered psychotropic drugs were recorded. The frequency of ECT was calculated by identifying the total number of the hospitalized patients during the study period from the hospital records.ResultsA total number of 1,432 female and 1,141 male patients hospitalized in a period of 7 years, with a total number of 111 patients treated with ECT. The ratio of ECT was 4%, maintenance/acute ECT 11%. For acute ECT, affective disorders (65.3%) and psychotic disorders (21.6%) were among the leading diagnoses. Maintenance ECT, the diagnosis was; 6 affective disorders, 4 psychotic disorders and 1 obsessive compulsive disorder. There was a significant difference between the patients receiving acute and maintenance ECT in terms of age, duration of illness, and number of previous hospitalizations and ECTs.ConclusionThe percentage of patients treated with acute ECT is lower in our institution than that in many other institutions from our country. Acute and maintenance ECT should be considered as an important treatment option particularly for patients with long disease duration, a high number of hospitalizations and a history of benefiting from previous ECTs.

Efficacy of Electroconvulsive Therapy in Bipolar Disorder with Mixed Features.

Introduction. Mixed states represent a frequent presentation of bipolar disorder, associated with higher resistance to psychopharmacology. Limited evidence supports the use of ECT in these patients. We aim to report our experience on treating bipolar mixed states with ECT. Methods. Retrospective data were collected from all bipolar patients submitted to acute ECT treatment, between June 2006 and June 2011. Three groups were created in terms of affective polarity of the episode. CGI rating was used to establish clinical remission and demographic and clinical variables were compared among groups. Long-term outcome was assessed through readmission measures, considering the use of continuation or maintenance ECT. Results. During the study time frame, a total of 50 ECT course treatments were performed on 41 bipolar patients. All affective episodes, except one mixed state, showed a positive clinical response. Patients with mixed state presentation tended to be younger and have an earlier first hospitalization than depressed patients. No differences were found in terms of ECT sessions performed, length of hospital admission, referral to continuation ECT treatment, number of readmissions, and time until next readmission. Conclusions. Our results support the effectiveness of ECT in patients experiencing a mixed affective state.

Evaluation of the efficacy of the continuation electroconvulsive therapy in treatment-resistant schizophrenia

Background : Electroconvulsive therapy (ECT) has been reported being a safe and effective treatment in schizophrenia. However, there are a limited number of studies assessing continuation ECT utilization in patients with schizophrenia giving partial response to pharmacological treatment. Objective : The aim of this study is to evaluate the effectiveness of continuation ECT in preventing relapse in patients with treatment-resistant schizophrenia. Methods : In this retrospective analysis, schizophrenia patients (n = 73) were defined in three groups such as patients who received only AP treatment (only AP), patients who received acute ECT only during hospitalization (aECT+AP), patients who received acute ECT and continuation ECT (a-cECT+AP). Three groups were compared according to positive and negative syndrome scale (PANSS) and Brief Psychiatric Rating Scale (BPRS) scores. Results : As per comparison of only AP group, aECT+AP group and a+cECT+AP groups in terms of after discharge PANSS and after discharge BPRS scores for 1st month, 3rd month and 6th month; 3rd and 6th month’s PANSS scores of a+cECT+AP group were statistically significantly lower than other two groups. Discussion : Although this study suffers the limitations of retrospective medical chart analysis, results suggest that, in patients with a diagnosis of schizophrenia who have responded to an acute course of ECT, continuation ECT in combination with antipsychotics is more effective than antipsychotics alone in preventing relapse.

Bridging the Gap: Combining Somatic and Psychological Interventions

The prediction of the World Health Organization that, by 2020, major depression will be second only to ischemic heart disease as a cause of disability highlights the importance of pursuing novel treatment approaches to this intractable psychiatric problem. In their article in Biological Psychiatry, Brakemeier et al. (1) illustrate the implementation of one novel approach by using talk therapy to prolong the robust but shortlived antidepressant effects of a somatic therapy for severe depression. Although research efforts regarding pharmacologic and psychotherapeutic approaches have recently been attracting growing attention, far less attention has been paid to combining treatment modalities to achieve a synergistic effect. Electroconvulsive therapy (ECT) is an effective and rapidly acting treatment of severe major depressive disorder with initial success rates commonly reported in the range of 60%–90% (2). However, relapse rates are notoriously high, and the field continues to strive for evidenced-based guidelines to sustain the antidepressant effect of ECT. To date, recommendations for immediate follow-up care have focused exclusively on continued medication, timing and combination of medications, and various schedules of continuation and maintenance ECT. Thinking outside the proverbial “somatic” box, Brakemeier et al. note that cognitive-behavioral therapy (CBT) has an evidenced-based reputation for sustaining antidepressant response. In the treatment of acute depression, CBT is as effective as antidepressant medication, and evidence exists for its prophylactic effects in reducing relapse in chronic depression (3). Studies have shown that CBT and related talk therapies can be beneficial to depressed patients who show only a partial response to medication (4) and when

Electroconvulsive therapy reappraised

Electroconvulsive therapy reappraised