Electroconvulsive Therapy Research Articles

Safety and efficacy of repetitive stimulation of the left dorsolateral prefrontal cortex using transcranial focused ultrasound in treatment-resistant depressed patients: A non-inferiority randomized controlled trial protocol

BackgroundAbout 30% of patients diagnosed with major depressive disorder fail with the mainstream pharmacological treatment. Patients who do not achieve clinical remission of symptoms, even with two different antidepressants, are classified with treatment-resistant depression (TDR). This condition imposes an additional burden with increased Disability Adjusted Life Years. Therefore, complementary treatments, such as neuromodulation, are necessary. The transcranial focused ultrasound (tFUS) has emerged in the past few years as a reliable method for non-invasive neuromodulation in humans and may help treat TRD. This study aims to propose a research protocol for a non-inferiority randomized clinical trial of TDR with tFUS. MethodsPatients with documented TRD will be screened upon entering the TRD outpatient clinic at UFMG (Brazil). One hundred patients without a clinical history of other psychiatric illness, anatomical abnormalities on magnetic resonance imaging (MRI), or treatment with electroconvulsive therapy will be invited to participate. Patients will be randomized (1:1) into two groups: 1) treatment with a previously established protocol of transcranial magnetic stimulation; and 2) treatment with a similar protocol using the stimulation. Besides regular consultations in the outpatient clinic, both groups will attend 7 protocolled spaced days of brain stimulation targeted at the left dorsolateral prefrontal cortex. They will also be submitted to 4 sessions of image studies (2 MRIs, 2 positron-emission tomography), 3 of neuropsychological assessments (at baseline, 1 week and 2 months after treatment), the Montgomery-Åsberg Depression Rating Scale to analyze the severity of depressive symptoms. DiscussionThis clinical trial intends to verify the safety and clinical efficacy of tFUS stimulation of the dorsolateral prefrontal cortex of patients with TRD, compared with a previously established neuromodulation method.

An audit and analysis of electro convulsive therapy patient information sheets used in local health districts in New South Wales Australia.

Electroconvulsive Therapy (ECT) is a widely used psychiatric treatment; however, it remains contentious. It is therefore important that people are provided with accurate and balanced information before consenting to ECT. The aim of this study was to audit and analyse the content and language of ECT information sheets used in local health districts (LHDs) across the state of New South Wales Australia. Descriptive content analysis and evaluative linguistic analysis were used to investigate the information sheets, with findings then considered from a mad studies perspective. Thirteen ECT information sheets were obtained and reviewed, with the audit finding they lacked accuracy and balance. Linguistic tools were used to exaggerate positive outcomes and minimise negative effects. Despite commonalities, the structure and content of the sheets varied considerably. Findings indicate a need for co-design and co-production approaches to developing ECT information sheets. This should occur in genuine partnership with lived experience representatives based on current evidence, using neutral language, and with attention to their intent as part of processes of informed consent and decision making.

Availability of Electroconvulsive Therapy in Public Health Services in the Last Decade in Brazil.

To identify the current treatment options for electroconvulsive therapy (ECT) therapy in public services linked to the Unified Health System in Brazil and compare them with data published in 2012 based on their availability. In this retrospective observational study, we mapped institutions that perform ECT under public health services in Brazil. A questionnaire was administered to active and inactive service centers between August 2022 and June 2023. We identified 16 institutions that performed ECT, including 12 linked to public universities and 4 with various links. In the last decade, 2 new public services that perform ECT in the country have emerged, whereas 4 services have ceased function. In 2022, the number of individuals treated with ECT per 100,000 population was 1.86, whereas the number of procedures performed per 100,000 people was 6.55. Although 2 new public ECT services have been identified, 4 have turned inactive. Most services are linked to public universities, and inactive service points to financial issues as the main factor in service interruption. Brazil has one of the lowest rates of individuals treated with ECT per 100,000 population compared with countries in North America and Europe. Thus, it is essential to raise awareness to improve ECT adoption rates and bring it out of the shadows in Brazil.

Efficacy and safety assessment of different electrode placements during electroconvulsive therapy for the treatment of depression: a comparison of bitemporal, bifrontal and unilateral right-sided stimulation - a narrative review

Introduction: Consequences of depressive syndrome are changes in central nervous system, especially the reduction in volume and disturbances in neuronal metabolism. There are disturbances in cerebral blood flow, in areas responsible for concentration, memory and regulation of behaviour and emotions. ECT method has shown considerable effectiveness in treatment of depression. It has invariably remained effective as a form of treatment in psychiatry for many years. The way in which the method itself is applied and location of stimulation electrodes remains controversial. In clinical practice, bitemporal, bilateral or right unilateral applications are used, each of which activates slightly different regions in brain, resulting in different therapeutic effects. Methods: A review of available literature was performed by searching PubMed and Google Scholar databases, using the following keywords: bifrontal ECT, bitemporal ECT, right unilateral ECT, cognitive function for original papers, meta-analyses and review papers in Polish and English published from 1990 to 2022. The SANRA scale was used to maintain the high quality of the narrative review. Results: All three methods are effective in treating depressive disorders, but differ in impact on cognitive function. Bi-frontal stimulation is the most effective in emergencies, however related to a higher risk of cognitive impairment. Milder cognitive impairment, with similar therapeutic efficacy, is observed with bitemporal and unilateral placement. Conclusions: Individualised selection of ECT method is recommended, depending on patients' needs and clinical condition. The importance of individualising the dose, location of electrodes, and monitoring of cognitive function is emphasised in order to increase the effectiveness and minimise side effects. Keywords: bifrontal ECT, bitemporal ECT, right unilateral ECT, cognitive function

Intravenous Ketamine for Suicidal Behavior in Severe Depression with Psychotic Features

Abstract Depression is the leading cause of suicide, and antidepressants and modified electroconvulsive therapy (mECT) are the preferred treatment modalities. Ketamine is an established anesthetic agent and evidence for its use in depression is evolving. Here, we discuss the experience of treating severe depression with intravenous (IV) ketamine. A patient in his mid-forties presented with a 2-month history of pervasive low mood, altered biological functions, decreased interest, and suspiciousness and was diagnosed with severe depression with psychotic features and suicidal ideas. As per the guidelines, started on antidepressants and planned for mECT. As the patient and family members were not willing for mECT, based on evidence, IV ketamine was discussed and started. Over six sessions of IV ketamine, there was significant improvement in both objective rating scores and clinically. IV ketamine can be a good adjunctive in the treatment of severe depression with suicidal ideas but needs to be backed up by robust studies.

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

BackgroundMore evidence is needed to validate the use of ECT in adolescent depression. This study aims to compare the effectiveness of electroconvulsive therapy (ECT) to conventional medication therapy for adolescents with major depression with suicidal ideation. MethodsIn this retrospective cohort study, we reviewed inpatient records from the First Affiliated Hospital of Chongqing Medical University spanning December 2016 to June 2021. We focused on adolescents diagnosed with severe depression presenting with suicidal tendencies. To equalize baseline differences between patients, we used the one-to-one propensity score matching to match patients who received ECT treatment with those who did not. Multivariate regression analysis was utilized to adjust for potential confounders, and subgroup analyses and sensitivity analyses were conducted to verify the robustness of our findings. ResultsOf the 626 patients in this study, 474 underwent ECT treatment while 152 received medication treatment, all aged between 10 and 18 years. Once matched, each group contained 143 patients. The ECT group demonstrated a significantly higher response rate and greater reductions in both Hamilton Depression Rating Scale and Hamilton Anxiety Scale scores (all P < 0.001). Additionally, the ECT group was more effective in reducing suicidal ideation, with fewer individuals retaining such ideation at discharge. In the multivariable regression analysis, both ECT treatment and shorter disease duration were independently linked to enhanced antidepressant efficacy. Subgroup analyses and sensitivity analyses verified the robustness of the main study effect. ConclusionsFor adolescents with major depressive disorder and suicidal ideation, combining ECT with pharmacotherapy is more effective than pharmacotherapy alone before medications reach full effect.

Development, validation and clinical utility of short-term adverse-effects of electroconvulsive therapy (SAVE) checklist

Electroconvulsive therapy (ECT) is one of the most effective treatments in psychiatry. However, it has many cognitive and non-cognitive adverse effects (AEs). There are lacunae in the literature on systematic assessment of non-cognitive AEs. There is a need for a standard, comprehensive and specific clinical tool to evaluate this. Hence, a checklist of short-term AEs of ECT (SAVE) with a 2-phase assessment was developed. Content validation was done using 15 experts’ ratings and predefined content validity ratio and index (CVR and CVI) in a two-stage modified Delphi method. The checklist had a good CVR and CVI with a final tool of 39 items. The tool was sensitive and identified the non-cognitive AEs after ECT. Cardiovascular and musculoskeletal systems displayed the highest incidence. Many participants exhibited delayed recovery in orientation, gait, and stance, highlighting a necessity for meticulous monitoring. SAVE is the first standardised tool to assess short-term ECT-related AEs systematically. This checklist likely identifies clinically significant incidences of adverse effects. Its regular use may enhance the safety of ECT and patient comfort by supporting early identification and intervention for AEs. However, given the transient nature of AEs, further studies are needed to determine their predictive validity for long-term consequences.

Clinical efficacy of adjunctive esketamine anesthesia in electroconvulsive therapy for major depressive disorders: A pragmatic, randomized, controlled trial

Electroconvulsive therapy (ECT) is an effective treatment for depression, and esketamine has been shown to have antidepressant effects. However, it is currently unclear whether adjunctive esketamine can enhance the clinical efficacy of ECT in real-world clinical practice. In this pragmatic clinical trial, patients with major depression were randomly assigned into two groups: patients received 0.25 mg/kg esketamine plus propofol (esketamine group) or the same volume of saline (control group) plus propofol. Results indicated that there was no difference in response and remission rates between the two groups. However, patients receiving esketamine had a higher remission rate of SI and lower psychotic scores. Patients receiving esketamine also required a lower electric dose, but the seizure duration and cognitive function were comparable between the two groups. Diastolic blood pressure increased after esketamine injection, but there was no increased risk of hypertension. Furthermore, incidence of delirium and confusion were comparable between the groups. Conclusively, adjunctive esketamine anesthesia does not provide any advantage in improving the response and remission rates of ECT. However, it can improve remission of SI and alleviate accompanying psychotic symptoms in depressive patients. With adjunctive usage, the adverse cardiovascular and neuropsychiatric events associated with esketamine appear to be tolerable.

Access to interventional psychiatric treatments in the United States: Disparities and proposed solutions

Interventional psychiatric treatments are a group of mental health procedures and monitored pharmacological interventions that are implemented when first-line therapies, such as psychotherapy and traditional pharmacotherapy, are ineffective or when there is a need for rapid symptom relief. Interventional treatments such as repetitive transcranial magnetic stimulation, esketamine, and electroconvulsive therapy are the United States Food and Drug Administration -approved treatments for major depressive disorder that has gained increased use and shows promise for improvement in efficacy and greater adoption. Despite the immense value and potential of interventional therapies, there are disparities in access to these treatments owing to economic, cultural, and geographical factors. When compounded with existing disparities in mental health care for racial and ethnic minorities, this interaction worsens inequities in access and may exacerbate the severity of disease in underserved groups. This review describes the factors contributing to these disparities, suggests strategies to ameliorate inequities, and broadens the impact of interventional therapies.

A Comparison of the Efficacy and Adverse Effects of Ketamine and Electroconvulsive Therapy in the Management of Treatment-Resistant Depression: A Systematic Review.

Ketamine has been repeatedly demonstrated to be an effective treatment in the management of patients with treatment-resistant depression (TRD). An important question is whether it is equally or more effective than the current gold standard of electroconvulsive therapy (ECT), as the adverse effects of ECT can lead to memory loss and neurocognitive deficits. A literature search was conducted for trials that directly compared the efficacy and adverse effects of ketamine and ECT via PubMed and Google Scholar. A total of 56 articles were identified with six included in this review. The studies included differed significantly in their qualityand with differing levels of potential for bias. Ketamine has a more immediate effect when compared to ECT, but the antidepressant effects are shorter-lasting. Cognitive deficits were less pronounced in patients undergoing ketamine therapy. Many studies had a small number of participants and varied widely in the type of ECT used. Allocation bias seems likely in nonrandomized studies. Follow-up times were also short in some studies. The existing literature does not provide sufficient evidence to support the usage of ketamine over that of ECT for TRD, as remission rates were significantly higher over extended periods in ECT groups. Cognitive adverse effects were more pronounced in patients undergoing ECT. More high-quality randomized controlled trials (RCTs) directly comparing these two treatment modalities are required before drawing any firm conclusions.

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

Electroconvulsive therapy (ECT) is widely used for treatment-resistant depression. However, it is unclear whether/how ECT can be targeted to affect brain regions and circuits in the brain to dynamically regulate mood and cognition. This study used brain entropy (BEN) to measure the irregular levels of brain systems in 46 major depressive disorder (MDD) patients before and after ECT treatment. Functional connectivity (FC) was further adopted to reveal changes of functional couplings. Moreover, transcriptomic and neurotransmitter receptor data were used to reveal genetic and molecular basis of the changes of BEN and functional connectivities. Compared to pretreatment, the BEN in the posterior cerebellar lobe (PCL) significantly decreased and FC between the PCL and the right temporal pole (TP) significantly increased in MDD patients after treatment. Moreover, we found that these changes of BEN and FC were closely associated with genes' expression profiles involved in MAPK signaling pathway, GABAergic synapse, and dopaminergic synapse and were significantly correlated with the receptor/transporter density of 5-HT, norepinephrine, glutamate, etc. CONCLUSION: These findings suggest that loops in the cerebellum and TP are crucial for ECT regulation of mood and cognition, which provides new evidence for the antidepressant effects of ECT and the potential molecular mechanism leading to cognitive impairment.

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

The molecular mechanism of electroconvulsive therapy (ECT) for schizophrenia remains unclear. The aim of this study was to uncover the underlying biological mechanisms of ECT in the treatment of schizophrenia using a transcriptional dataset. The peripheral blood mRNA sequencing data of eight patients (before and after ECT) and eight healthy controls were analyzed by integrated co-expression network analysis and the differentially expressed genes were analyzed by cluster analysis. Gene set overlap analysis was performed using the hypergeometric distribution of phypfunction in R. Associations of these gene sets with psychiatric disorders were explored. Tissue-specific enrichment analysis, gene ontology enrichment analysis, and protein-protein interaction enrichment analysis were used for gene set organization localization and pathway analysis. We found the genes of the green-yellow module were significantly associated with the effect of ECT treatment and the common gene variants of schizophrenia ( P = 0.0061; family-wise error correction). The genes of the green-yellow module are mainly enriched in brain tissue and mainly involved in the pathways of neurotrophin, mitogen-activated protein kinase and long-term potentiation. Genes associated with the efficacy of ECT were predominantly enriched in neurotrophin, mitogen-activated protein kinase and long-term potentiation signaling pathways.

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

Seizure quality is considered to be associated with treatment outcomes of electroconvulsive therapy (ECT). A wide range of treatment parameters and patient characteristics are known to influence seizure quality. However, conflicting results exist for the role of serum electrolyte levels and seizure quality. We retrospectively analyzed a total of 454 patients and a total of 2119 individual acute ECT sessions irrespective of diagnosis where a clinical evaluation of serum levels of sodium, potassium, and calcium took place routinely up to 2 days before the ECT session. To assess the impact of serum electrolyte levels on seizure quality parameters, we used mixed-effects linear regression analysis with Bonferroni correction for multiple testing. Serum sodium, potassium, and calcium levels were not associated with seizure quality markers after correcting the significance level for multiple testing. Younger age was consistently associated with higher postictal suppression, interhemispheric coherence, midictal amplitude, and peak heart rate. Lower dose was consistently associated with longer electroencephalogram and motor seizure duration. Our results suggest that there is no clinically relevant effect of serum electrolyte levels on seizure quality, at least within clinically commonly observed ranges of serum electrolyte concentrations.

Electroconvulsive Therapy Regulates Brain Connectome Dynamics in Patients With Major Depressive Disorder

BackgroundElectroconvulsive therapy (ECT) is an effective treatment for patients with major depressive disorder (MDD), but its underlying neural mechanisms remain largely unknown. The aim of this study was to identify changes in brain connectome dynamics after ECT in MDD and to explore their associations with treatment outcome. MethodsWe collected longitudinal resting-state functional magnetic resonance imaging data from 80 patients with MDD (50 with suicidal ideation [MDD-SI] and 30 without [MDD-NSI]) before and after ECT and 37 age- and sex-matched healthy control participants. A multilayer network model was used to assess modular switching over time in functional connectomes. Support vector regression was used to assess whether pre-ECT network dynamics could predict treatment response in terms of symptom severity. ResultsAt baseline, patients with MDD had lower global modularity and higher modular variability in functional connectomes than control participants. Network modularity increased and network variability decreased after ECT in patients with MDD, predominantly in the default mode and somatomotor networks. Moreover, ECT was associated with decreased modular variability in the left dorsal anterior cingulate cortex of MDD-SI but not MDD-NSI patients, and pre-ECT modular variability significantly predicted symptom improvement in the MDD-SI group but not in the MDD-NSI group. ConclusionsWe highlight ECT-induced changes in MDD brain network dynamics and their predictive value for treatment outcome, particularly in patients with SI. This study advances our understanding of the neural mechanisms of ECT from a dynamic brain network perspective and suggests potential prognostic biomarkers for predicting ECT efficacy in patients with MDD.

Synergetic Effect of Electroconvulsive Therapy and Clozapine therapy in Treating Severe Intractable Aggressive Behaviour in an Adult with Intellectual Disability: A Case Report

Synergetic Effect of Electroconvulsive Therapy and Clozapine therapy in Treating Severe Intractable Aggressive Behaviour in an Adult with Intellectual Disability: A Case Report

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

BackgroundRECOVER is a randomized sham-controlled trial of vagus nerve stimulation and the largest such trial conducted with a psychiatric neuromodulation intervention. ObjectiveTo describe pre-implantation baseline clinical characteristics and treatment history of patients with unipolar, major depressive disorder (MDD), overall and as a function of exposure to interventional psychiatric treatments (INTs), including electroconvulsive therapy, transcranial magnetic stimulation, and esketamine. MethodsMedical, psychiatric, and treatment records were reviewed by study investigators and an independent Study Eligibility Committee prior to study qualification. Clinical characteristics and treatment history (using Antidepressant Treatment History [Short] Form) were compared in those qualified (N = 493) versus not qualified (N = 228) for RECOVER, and among the qualified group as a function of exposure to INTs during the current major depressive episode (MDE). ResultsUnipolar MDD patients who qualified for RECOVER had marked TRD (median of 11.0 lifetime failed antidepressant treatments), severe disability (median WHODAS score of 50.0), and high rate of baseline suicidality (77% suicidal ideation, 40% previous suicide attempts). Overall, 71% had received at least one INT. Compared to the no INT group, INT recipients were younger and more severely depressed (QIDS-C, QIDS-SR), had greater suicidal ideation, earlier diagnosis of MDD, and failed more antidepressant medication trials. ConclusionsRECOVER-qualified unipolar patients had marked TRD and marked treatment resistance with most failing one or more prior INTs. Treatment with ≥1 INTs in the current MDE was associated with earlier age of MDD onset, more severe clinical presentation, and greater treatment resistance relative to patients without a history of INT. Trial registrationClinicalTrials.gov Identifier NCT03887715.

Effect of Different Doses of Sugammadex on Recovery and Hemodynamic Parameters in Reversing Neuromuscular Blockade in Patients Undergoing Electroconvulsive Therapy.

This retrospective observational study aimed to investigate the effect of different doses of sugammadex used in reversing neuromuscular blockade in electroconvulsive therapy (ECT) procedures on patient recovery and hemodynamic measurements. Anesthesia induction was performed using propofol (1 mg/kg) and rocuronium (0.4 mg/kg). Patients were classified into group 2 (2 mg/kg) and group 3 (3 mg/kg) according to the dose of sugammadex used to reverse neuromuscular blockade. The patient's spontaneous breathing time, eye-opening time, time to comply with voluntary commands, time to reach Modified Aldrete score (MAS) 9, complications, and hemodynamic data were analyzed. In total, 314 ECT sessions were performed on 46 patients. The average age of the patients was 38.3±12.6 years, and 56.6% (n=26) were male. While the average number of ECTs applied to the patients was 6.8±2.8, the average seizure duration was 28.2±12.7 seconds. The most common diagnosis (32.7%) in patients who underwent ECT was bipolar disorder. The average time to recovery of spontaneous breathing, eyeopening time, time to comply with voluntary commands, and time to reach MAS 9 were found to be significantly lower in group 3 (p<0.001, p<0.001, p<0.001, and p=0.002, respectively). Tooth damage was observed in 0.3% (n=1) and tongue abrasion in 0.6% (n=2) of the cases. Hemodynamic measurements were similar between groups (p>0.05). Sugammadex used at a dose of 3 mg/kg in ECT procedures significantly reduces recovery times compared with 2 mg/kg. However, both doses can be safely and cost-effectively used to reverse the neuromuscular blockade provided by 0.4 mg/kg rocuronium.

The role of carbon dioxide in electroconvulsive therapy: Assessing the necessity of forced hyperventilation

The role of carbon dioxide in electroconvulsive therapy: Assessing the necessity of forced hyperventilation

Assessing the Efficacy of Methods for Treatment-Resistant Depression: A Review

Electroconvulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS), and Esketamine have all been proven to be effective against treatment-resistant depression (TRD). However, it is still unclear which method of treatment is the most effective both in general and in specific populations of patients exhibiting certain traits (i.e. psychosis) or with varied severities of TRD. ECT is the oldest form of treatment and has been proven effective, though not without significant side effects. TMS has also been shown to be effective, but without the side effects of ECT. Esketamine is the newest form of treatment for TRD, only having been approved by the FDA in 2019. Although current research demonstrates its efficacy, little research has been done on this modality because of its novelty. Trials from 2000-2019 were searched for and utilized to examine the efficacy of these three treatments in comparison to each other. The most recent and relevant studies were chosen. Studies completed before 2000 or utilizing patients without qualifying criteria for TRD were not included in our review. The data analyzed suggest that ECT is the most effective form of treatment overall, but TMS is noninferior in nonpsychotic patients and esketamine is effective for patients with TRD and no other chronic comorbidities.

Maintenance Electroconvulsive Therapy in Catatonia: Clinical Profiles From a Case Series.

This study aims to conduct a descriptive analysis of the clinical features and treatment responses in 6 patients with catatonia who received maintenance electroconvulsive therapy (ECT). Our study included all patients who underwent maintenance ECT (mECT) at the Hospital Clínic de Barcelona between September 2020 and September 2022 following a catatonic episode. The study cohort comprised 5 patients with schizophrenia and 1 patient with major depressive disorder. Among patients with schizophrenia, the first catatonic episode occurred several years after their initial paranoid psychotic episode, whereas the patient with depression experienced a rapid progression from the first depressive episode to catatonia. After acute ECT, 4 patients achieved complete symptomatic remission, 1 patient exhibited a partial response, and another maintained a severe catatonic state. Maintenance ECT was indicated because of the high risk of severe relapses. The mean frequency of mECT sessions was 9.83 (SD, 5.60) days. Notably, 66.67% of the patients were concurrently receiving clozapine as part of their pharmacological treatment. Among patients with schizophrenia, mECT sessions could not be extended beyond 7 to 10 days, whereas the depressed patient could space ECT sessions up to 21 days without experiencing a relapse. Maintenance ECT proves to be a safe and well-tolerated strategy for preventing relapses in severe catatonic patients who have previously stabilized with acute ECT. Further research is needed to develop clinical guidelines that define optimal application strategies for mECT in catatonia.