Course Of Electroconvulsive Therapy Research Articles

Preliminary Guidelines for Resuming Electroconvulsive Therapy After a Complication of Status Epilepticus.

Electroconvulsive therapy (ECT) is an effective and safe treatment for severe major depressive disorder. However, status epilepticus is a rare yet serious complication that can occur following treatment. We present a case of a patient with severe major depression who experienced convulsive status epilepticus during the first treatment of her fourth ECT course. Electroconvulsive therapy treatment was then discontinued, and the patient underwent unsuccessful medication trials. Due to deterioration of depressive symptoms, ECT resumption was considered 3 months later after the patient had been maintained on an antiepileptic drug and no further seizures had occurred. Electroconvulsive therapy was resumed with a detailed safety protocol that included electroencephalographic monitoring before and after ECT treatment, remaining on an antiepileptic drug during the course of treatment, performing ECT in the operating room, and preparing seizure-terminating drugs before each treatment. The patient completed her ECT course with no tardive seizures or other neurological complications. We present the safety measures taken for resumption of ECT in our patient, and we offer preliminary clinical guidelines for resuming ECT after a complication of status epilepticus.

Reliable Change Indices and Minimum Detectable Change for the Montreal Cognitive Assessment in Electroconvulsive Therapy for Depression.

The Montreal Cognitive Assessment (MoCA) is a commonly used brief cognitive screening tool for monitoring adverse cognitive effects of electroconvulsive therapy (ECT). The aim of this study was to examine three statistical methods for detecting reliable change in the MoCA following ECT. In a prospective cohort study, 47 patients (mean age 55.2 [SD = 12.8], 59.6% female) with unipolar or bipolar depression treated with an acute course of brief-pulse ECT (72.3% right unilateral) and 47 depressed controls without ECT exposure were tested on the MoCA at baseline and retested at comparable time intervals. ECT patients' performance was also compared to published normative data from a community-based sample of older adults. We calculated proportions of ECT patients remaining stable, declining, and improving following ECT using practice-corrected reliable change index, standardized regression-based formulas, and minimum detectable change cutoff of ±4 MoCA points. Using the three methods, 72.3%-78.7% of ECT patients remained stable, 17.0%-23.4% declined, and 4.3% improved in MoCA performance following ECT compared to the two control groups. All three methods yield consistent estimates of reliable change in MoCA scores from pre- to post-brief-pulse ECT. The minimum detectable change approach may be the most efficient and accessible method of detecting change due to simplicity of calculation.

Electroconvulsive therapy in a tertiary Australian mental health facility between 2009 and 2020.

Despite electroconvulsive therapy being one of the most effective treatments in psychiatry, few studies report trends in the provision of electroconvulsive therapy over time. This study aims to investigate the use of electroconvulsive therapy between 2009 and 2020 in an Australian public tertiary mental health facility, and to describe the electroconvulsive therapy patient population and change in courses of treatment. Routinely collected data for 677 patients who received 1669 electroconvulsive therapy courses of treatment at an Australian public tertiary mental health facility between 2009 and 2020 were examined. The provision of acute electroconvulsive therapy was stable across the study period; however, the number of maintenance electroconvulsive therapy courses commenced declined over the study. Schizophrenia was the most common indication for index treatment (37.4%). The majority of patients (85.7%) received acute electroconvulsive therapy only. Voluntary provision of electroconvulsive therapy declined over the study period, reducing from 44.9% in 2009 to 16.3% in 2020. Over the study period, there was a significant reduction in the number of maintenance electroconvulsive therapy courses commenced, and a large increase in involuntary treatment. The provision of electroconvulsive therapy was more likely to occur in males with a diagnosis of schizophrenia. Further studies are needed to generate a greater understanding of the factors influencing the provision of electroconvulsive therapy within differing geographical, social and healthcare landscapes.

Successful Treatment of Both Refractory Neuroleptic Malignant Syndrome and Subsequent Catatonia With Electroconvulsive Therapy in a Patient With Suspected Kufs Disease.

We describe a patient suffering from probable Kufs disease who developed a neuroleptic malignant syndrome (NMS) after use of an antipsychotic agent over some weeks during hospitalization due to neuropsychiatric symptoms. Transferred to the neurology department, the patient quickly developed catatonic features. She did not respond to usual medical treatment but did respond to electroconvulsive therapy (ECT). The patient worsened following a nosocomial SARS-CoV-2 infection but improved again during a second course of ECT. We discuss Kufs disease as a potential risk factor for NMS and address the link between NMS and catatonia as well as the indication for ECT in both disorders. We also discuss the impact of SARS-CoV-2 infection on the clinical outcome. We describe the long recovery process and the secondary worsening of the patient on a cognitive level.

Stakeholders’ perspectives on adverse effects of ECT: A qualitative thematic analysis

Background: In the Indian context, published systematic research on the opinions of mental health professionals and other stakeholders (patients and caregivers) regarding the different adverse effects of electroconvulsive therapy (ECT) is not available. This type of study allows for an in-depth exploration of complex phenomena, such as the perspectives of mental health professionals, which can provide a rich understanding of their experiences regarding ECT and also helps to understand the views of mental health professionals regarding the adverse effects of ECT during the post-ECT recovery period and its management. Conversely, the perception of patients and caregivers regarding the adverse effects of ECT can provide a more comprehensive understanding of the treatment and its impact on the patients who receive it. Purpose: To explore the understanding of participants about the various adverse effects following ECT and their perception of managing different adverse effects of ECT during the post-ECT recovery period. Methods: A qualitative approach using focus group discussion (FGD) was used. A convenience sampling technique was followed for selecting the participants. FGDs were conducted with stakeholders including mental health professionals, patients, and caregivers. Five FGDs were conducted with psychiatry residents, nursing officers from the ECT suite, and different psychiatry wards at NIMHANS. Four FGDs were held separately for patients receiving ECT and their caregivers, admitted to various psychiatry wards at NIMHANS. A total of 28 mental health professionals, 20 patients, and 20 caregivers participated. The number of participants for FGDs was decided based on data saturation. The FGDs, lasting 30–40 minutes each, occurred between October 2022 and December 2022. The FGDs were audio-recorded with prior permission from the participants. All the participants were informed about the study. Written informed consent was obtained. All FGDs were transcribed. Thematic analysis was done using Atlas. ti software. Results: The broad categories identified were adverse events associated with ECT during the ECT procedure, adverse events associated with ECT after the ECT procedure, prevalence of different adverse effects according to mental health professionals, effects of adverse effects on the continuity of ECT, and difficulties encountered by mental health professionals throughout the management. Other broad categories were found after conducting FGDs with caregivers and patients, which were patients’ experience as per the caregivers over the course of ECT, caregivers’ and patients’ willingness to continue ECT, unfavorable impacts of ECT experienced by the patients immediately after ECT sessions, and, later till the end of that day, suggestions of the caregivers and patients to improvise the management of ECT-related adverse effects and management of adverse effects by the treating team. Conclusion: The findings will develop a standard operating procedure that may help nursing officers monitor and identify the adverse effects immediately after ECT and minimize the complications during the post-ECT recovery period.

Comparison of microRNA expression levels in patients with schizophrenia before and after electroconvulsive therapy.

Exploring the role of microRNAs in the antipsychotic efficacy of electroconvulsive therapy (ECT) will contribute to understanding the underlying mechanism through which ECT exerts its therapeutic effects. The primary objective of this study was to identify microRNA alterations before and after ECT in patients with schizophrenia. We compared microarray-based microRNA profiles in peripheral blood from eight patients with schizophrenia before and after ECT and eight healthy controls. Then, we aimed to validate selected differentially expressed microRNAs in 30 patients with schizophrenia following a course of ECT, alongside 30 healthy controls by using quantitative real-time PCR (qRT-PCR). Microarray-based expression profiling revealed alterations in 681 microRNAs when comparing pre- and post-ECT samples. Subsequent qRT-PCR analysis of the selected microRNAs (miR-20a-5p and miR-598) did not reveal any statistical differences between pre- and post-ECT samples nor between pre-ECT samples and those of healthy controls. As neuroepigenetic studies on ECT are still in their infancy, the results reported in this study are best interpreted as exploratory outcomes. Additional studies are required to explore the potential epigenetic mechanisms underlying the therapeutic efficacy of ECT.

Electroconvulsive Therapy in Refractory and Super-Refractory Status Epilepticus in Adults: A Scoping Review.

Electroconvulsive therapy (ECT) has been suggested as a treatment option for refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE). The objective of this scoping review was to conduct an extensive literature review on the role of ECT as a treatment option for RSE and SRSE. We searched Ovid MEDLINE and Scopus for journal articles from database inception until February 2024. Articles were then selected based on predetermined inclusion and exclusion criteria. We identified five retrospective case series with 28 adult patients receiving ECT for RSE or SRSE. ECT was administered within 3-70days (mean 20days) after the development of SE, and the mean number of ECT courses ranged from 1 to 12 sessions for each patient. ECT was administered in fixed or titrated doses. A total of 20 out of 28 patients (71%) showed clinical improvement, with two (7%) having complete cessation of seizures. It is essential to note that given the lack of control, there could be overreporting of clinical improvement in these studies. 11 patients (39%) were reported as deceased due to causes that were not directly related to ECT treatment. Four patients (14%) reported adverse effects of ECT, including memory, concentration, and/or cognitive impairment. There are level-4 Oxford Centre for Evidence-Based Medicine evidence and low-level Grading of Recommendations Assessment Development and Education evidence that suggest ECT as a treatment option for RSE and SRSE. In light of the limitations of the existing evidence, clinicians should carefully consider individual patients' clinical contexts when deciding on the appropriateness of ECT as a treatment option. Further research, including prospective studies with controlled designs, is needed to elucidate the efficacy, safety, and optimal regime of ECT in the management of RSE and SRSE.

The influence of concomitant antidepressant and antipsychotic medication on antidepressant effect and seizure duration of electroconvulsive therapy.

A significant proportion of patients with a depressive disorder show resistance to pharmacological and psychotherapeutic antidepressant treatments. Electroconvulsive therapy (ECT) is still one of the most effective treatment methods, especially in the acute phase. In everyday clinical practice, this usually accompanies pharmacological treatment. It has been shown that pharmacological treatment following acute ECT treatment reduces the rate of relapses. However, the effect of various antidepressants (ADs) and antipsychotics (APs) on the effect during the course of ECT has rarely been investigated. In this retrospective chart review study, the data of 104 depressive patients treated with ECT were examined. We analyzed the influence of concomitant administration of AD and AP or no psychotropic medication on the effect of ECT using the Montgomery-Åsberg Depression Rating Scale (MADRS). We further analyzed the influence of the ADs Bupropion, Venlafaxine, and Sertraline or no AD and the influence of augmentation with Aripiprazole or Quetiapine or Olanzapine. Psychotropic medication did not have an impact on antidepressant efficacy of ECT as measured with the MADRS scores. In addition, the comparison between the antidepressant or antipsychotic medications themselves did not show any significant difference. However, we found a significantly different seizure duration depending on the antidepressant substance that patients received during ECT (p = .008). ECT treatment itself led to a highly significant reduction of 13.3 points in the MADRS (p <.001). Taken together, our study underlines that concomitant psychotropic medication while doing electroconvulsive therapy does not bare the risk of prolonged seizure duration or does it reduce the effectiveness of ECT. To the best of our knowledge, this study is the first to examine the effect of treatment with antidepressants in combination with antipsychotics while doing ECT. In light of our results, this combination therapy is safe and effective. Bearing in mind the delay in onset of antidepressant action of medication and the importance of antidepressant medication for relapse prevention, this study further supports the recommendation that psychotropic medication should be given in adjunction to ECT.

A woman with schizophrenia who died due to Takotsubo cardiomyopathy occurring after electroconvulsive therapy

BackgroundElectroconvulsive therapy (ECT) is a safe treatment for treatment-resistant schizophrenia. However, it has some side effects, and Takotsubo cardiomyopathy is considered one of the minor complications. Several cases of patients developing Takotsubo cardiomyopathy during a course of ECT have been reported, but none have died. We present a case of post-ECT Takotsubo cardiomyopathy that became fatal.Case presentationWe experienced a case of a 67-year-old woman who had delusions and catatonic symptoms due to schizophrenia but was resistant to several medications. Her symptoms improved by conducting ECT, but she had difficulty maintaining her improvement, which caused her to receive multiple courses of ECT. 3 weeks after her 6th course of ECT, the patient was diagnosed with Takotsubo cardiomyopathy and had a fatal outcome.ConclusionOur patient had numerous cases of aspiration pneumonia and malnutrition before ECT was performed, which might have made this case fatal. In conclusion, appropriate supplementation of nutrition and reduction of physical stressors are important to avoid death from Takotsubo cardiomyopathy caused by ECT. Prescribing clozapine was a solution in the present case, but there are some difficulties, such as the restriction against prescribing this drug in Japan.

The effect of transcranial direct current stimulation (tDCS) on cognitive function recovery in patients with depression following electroconvulsive therapy (ECT): protocol for a randomized controlled trial

BackgroundElectroconvulsive therapy (ECT) is a highly effective treatment for depressive disorder. However, the use of ECT is limited by its cognitive side effects (CSEs), and no specific intervention has been developed to address this problem. As transcranial direct current stimulation (tDCS) is a safe and useful tool for improving cognitive function, the main objective of this study was to explore the ability to use tDCS after ECT to ameliorate the cognitive side effects.Methods60 eligible participants will be recruited within two days after completing ECT course and randomly assigned to receive either active or sham stimulation in a blinded, parallel-design trial and continue their usual pharmacotherapy. The tDCS protocol consists of 30-min sessions at 2 mA, 5 times per week for 2 consecutive weeks, applied through 15-cm2 electrodes. An anode will be placed over the left dorsolateral prefrontal cortex (DLPFC), and a cathode will be placed over the right supraorbital cortex. Cognitive function and depressive symptoms will be assessed before the first stimulation (T0), after the final stimulation (T1), 2 weeks after the final stimulation (T2), and 4 weeks after the final stimulation (T3) using the Cambridge Neuropsychological Test Automated Battery (CANTAB).DiscussionWe describe a novel clinical trial to explore whether the administration of tDCS after completing ECT course can accelerates recovery from the CSEs. We hypothesized that the active group would recover faster from the CSEs and be superior to the sham group. If our hypothesis is supported, the use of tDCS could benefit eligible patients who are reluctant to receive ECT and reduce the risk of self-inflicted or suicide due to delays in treatment.Trial registration detailsThe trial protocol is registered with https://www.chictr.org.cn/ under protocol registration number ChiCTR2300071147 (date of registration: 05.06.2023). Recruitment will start in November 2023.

Effectiveness and Safety of Flumazenil Augmentation During Electroconvulsive Therapy.

Benzodiazepines are considered to negatively affect seizure quality and duration during electroconvulsive therapy (ECT). Several researchers have advocated the use of flumazenil, a competitive benzodiazepine receptor antagonist, for patients treated with benzodiazepines during ECT. However, clinical evidence regarding flumazenil use in ECT remains sparse. The aim of this study is to investigate the effects of flumazenil on seizure duration and adverse effects. All patients with depressive disorders, treated with flumazenil during a course of ECT in 2019 in a tertiary hospital, were identified through a retrospective chart review. Seizure duration was recorded before and after flumazenil administration. Effectiveness of ECT was assessed using the Inventory of Depressive Symptomatology and the Bush-Francis Catatonia Rating Scale. Postictal agitation was ascertained by identifying patients who received additional sedatives immediately after ECT or who needed physical restraint. Twenty-six patients were included, receiving a total of 363 treatments, of which 263 were augmented with flumazenil. Flumazenil administration increased electroencephalogram seizure duration on average with 10.5 seconds comparing ECT with or without flumazenil (P = 0.003). In 21.8% of the cases, no increase in seizure duration was observed. Postictal agitation occurred at least once in 34.6% of the patients receiving flumazenil during their course of ECT. Our results show that flumazenil increases seizure duration, albeit with limited clinical implications. Noteworthy, the prevalence of postictal agitation is high. When confronted with short seizures, clinicians should therefore deploy other available techniques to lower seizure threshold before considering flumazenil.

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.

ELECTROCONVULSIVE THERAPY FOR TREATMENT OF TACTILE HALLUCINATIONS

Abstract Tactile hallucinations can be highly distressing and lead to psychiatric morbidities and functional impairments. There are no established treatments for tactile hallucinations that occur outside of primary psychotic disorders, and available pharmacologic and nonpharmacologic therapies may have limited effectiveness. We present a case of a 75-year-old female with treatment-refractory tactile hallucinations successfully treated with electroconvulsive therapy (ECT). She endorsed 13 months of distressing tactile hallucinations described as slimly substances on her skin. Symptoms started insidiously, became more severe with time and refractory to multiple antipsychotic medications. She became so severely distressed from the tactile hallucinations that she developed a major depressive episode and became suicidal. Relevant medical history included one prior depressive episode, occipital lobe stroke, restless legs syndrome, and obstructive sleep apnea. She was hospitalized in an inpatient psychogeriatric unit and treated with ECT for 12 sessions over 3.5 weeks. Hallucinations responded well to ECT. Patient experienced some mild memory impairment from treatment. Treatment was optimized with duloxetine titration, addition of mirtazapine and repletion of B6 vitamin. Following the acute course of ECT, she reported an 80 % improvement in tactile hallucinations. Depressive symptoms improved, and suicidal thoughts resolved. She was able to discharge from the hospital and continued with maintenance ECT. Our case illustrates the potential therapeutic role of brain stimulation in the treatment of refractory cases of tactile hallucinations. Further studies are needed to determine effective treatment strategies for treatment-refractory tactile hallucinations to prevent progression to severe psychiatric disturbances and improve quality of life.

Efficacy and safety of ketamine-assisted electroconvulsive therapy in major depressive episode: a systematic review and network meta-analysis.

To meta-analyze clinical efficacy and safety of ketamine compared with other anesthetic agents in the course of electroconvulsive therapy (ECT) in major depressive episode (MDE). PubMed/MEDLINE, Cochrane Library, Embase, GoogleScholar, and US and European trial registries were searched from inception through May 23, 2023, with no language limits. We included RCTs with (1) a diagnosis of MDE; (2) ECT intervention with ketamine and/or other anesthetic agents; and (3) measures included: depressive symptoms, cognitive performance, remission or response rates, and serious adverse events. Network meta-analysis (NMA) was performed to compare ketamine and 7 other anesthetic agents. Hedges' g standardized mean differences (SMDs) were used for continuous measures, and relative risks (RRs) were used for other binary outcomes using random-effects models. Twenty-two studies were included in the systematic review. A total of 2322 patients from 17 RCTs were included in the NMA. The overall pooled SMD of ketamine, as compared with propofol as a reference group, was -2.21 (95% confidence interval [CI], -3.79 to -0.64) in depressive symptoms, indicating that ketamine had better antidepressant efficacy than propofol. In a sensitivity analysis, however, ketamine-treated patients had a worse outcome in cognitive performance than propofol-treated patients (SMD, -0.18; 95% CI, -0.28 to -0.09). No other statistically significant differences were found. Ketamine-assisted ECT is tolerable and may be efficacious in improving depressive symptoms, but a relative adverse impact on cognition may be an important clinical consideration. Anesthetic agents should be considered based on patient profiles and/or preferences to improve effectiveness and safety of ECT use.

Ketamine as an Alternative Anesthetic for Augmenting Seizure Durations During Electroconvulsive Therapy: A Retrospective Observational Study.

Electroconvulsive therapy (ECT) is highly effective for severe psychiatric disorders; however, short seizure durations may lead to ineffective therapy. This retrospective study aimed to examine the risks and benefits of switching to ketamine anesthesia to augment seizure durations during an acute course of ECT. We included 33 patients who underwent ketamine anesthesia due to suboptimal seizures during an acute course of ECT. We assessed seizure duration, stimulus dose, hemodynamic variability, and postseizure complications before and after switching to ketamine. Age was significantly associated with suboptimal seizures during ECT ( P = 0.040). After switching to ketamine, 32 patients (97%) experienced prolonged seizure duration. Ketamine significantly prolonged both electroencephalogram and motor seizure durations with a mean difference of 34.6 seconds (95% confidence interval [CI], 26.4-42.7 seconds; P < 0.001) and 26.6 seconds (95% CI, 19.6-33.6 seconds; P < 0.001), respectively. It also significantly reduced stimulus dose (mean difference, -209.5 mC [95% CI, -244.9 to -174.1 mC]; P < 0.001). In addition, maximum changes in systolic blood pressure and heart rate during ECT sessions significantly increased with ketamine (mean difference, 27.2 mm Hg [95% CI, 12.0-42.4 mm Hg; P = 0.001]; 25.7 beats per minute [95% CI, 14.5-36.8 beats per minute; P < 0.001], respectively). Patients reported more headaches with ketamine ( P = 0.041). Our results provide evidence that ketamine as an alternative anesthetic can augment seizure durations in specific patients experiencing suboptimal seizures during an acute course of ECT. However, its use requires greater attention to circulatory management and postseizure complications.

S7: Updates on Electroconvulsive Therapy practice and research

Electroconvulsive Therapy (ECT) has evolved into a highly safe, effective, and well tolerated treatment for several severe psychiatric conditions and has become a necessary tool in the armamentarium of modern psychiatry. In this symposium we will review current state of the art clinical practices in Electroconvulsive Therapy (ECT) and new data on research.More specifically Dr. Charles Kellner will review the elements of optimal patient selection/preparation in the ECT consultation and review clinical decision-making during a course of ECT (including electrode placement, stimulus dosing and other technical procedural details.)Dr Raphael Braga will review the evidence for the use of ECT as an augmentation to antipsychotic medications strategy for the treatment of patients with schizophrenia who are resistant to medications, including clozapine.Dr. Brent Forester will discuss the rationale and evidence base for the safety and efficacy of ECT for the treatment of Agitation in Dementia. Agitation is the most common neuropsychiatric symptom of dementia, accounts for about 12% of the total health and social care costs (approximately $31billion/year). It is implicated in a vicious cycle of negative events including deterioration of family and professional relationships, increased risk of death, and increased caregiver burden, which is a significant predictor for institutionalization or death of patients with dementia. His presentation will highlight the existing evidence base and method of ECT delivery to target symptoms of severe agitation, and review an ongoing multi-site NIA funded clinical trial of ECT for severe agitation in dementia.Dr Søren Dinesen Østergaard will discuss the suicide risk in patients receiving ECT which, despite the well-established anti-suicidal effect of ECT, remains high due to the severity of their underlying illness. He will present data quantifying and identifying risk factors for suicide among patients receiving ECT using data from nationwide Danish registers on 11,780 patients.Dr. Georgios Petrides is the organizer and will moderate this symposium

Electroconvulsive therapy related anxiety in patients with depression: The influence of cognitive coping styles.

Electroconvulsive therapy (ECT) related anxiety (ERA) is a common phenomenon with high individual variability. The way patients cognitively cope with the prospects of receiving ECT could be a mechanism explaining individual differences in ERA. Cognitive coping like monitoring (information seeking, paying attention to consequences) and blunting (seeking distraction and reassurance) has been linked to anxiety in various medical settings, with monitoring leading to more and blunting to less anxiety. How cognitive coping is related to ERA, is unknown. The sample consisted of 71 patients with unipolar or bipolar depression referred for ECT. Cognitive coping was assessed at baseline, while ERA was measured each morning before the ECT session. Using a Linear Mixed Model, the influence of cognitive coping styles on ERA was investigated. Blunting was associated with lower levels of ERA (p = 0.037) and monitoring tended to be associated with higher levels of ERA (p = 0.057) throughout the ECT course. Patients with a depression with psychotic features scored significantly higher on monitoring, but even after controlling for monitoring they showed a stronger decline in ERA during treatment compared to patients without psychotic features. Cognitive coping style contributes to individual differences in ERA. Blunting is a protective factor, leading to lower levels of ERA throughout the ECT course. On the contrary, patients with a higher monitoring style tend to experience higher levels of ERA. Further insights in these coping mechanisms may help to tailor future treatment to individual patients and reduce ERA before and during ECT treatment.

Cortical excitation/inhibition ratios in patients with major depression treated with electroconvulsive therapy: an EEG analysis

Electroconvulsive therapy (ECT) is an effective treatment for major depression, but its working mechanisms are poorly understood. Modulation of excitation/inhibition (E/I) ratios may be a driving factor. Here, we estimate cortical E/I ratios in depressed patients and study whether these ratios change over the course of ECT in relation to clinical effectiveness. Five-minute resting-state electroencephalography (EEG) recordings of 28 depressed patients were recorded before and after their ECT course. Using a novel method based on critical dynamics, functional E/I (fE/I) ratios in the frequency range of 0.5–30 Hz were estimated in frequency bins of 1 Hz for the whole brain and for pre-defined brain regions. Change in Hamilton Depression Rating Scale (HDRS) score was used to estimate clinical effectiveness. To account for test–retest variability, repeated EEG recordings from an independent sample of 31 healthy controls (HC) were included. At baseline, no differences in whole brain and regional fE/I ratios were found between patients and HC. At group level, whole brain and regional fE/I ratios did not change over the ECT course. However, in responders, frontal fE/I ratios in the frequencies 12–28 Hz increased significantly (pFDR < 0.05 [FDR = false discovery rate]) over the ECT course. In non-responders and HC, no changes occurred over time. In this sample, frontal fE/I ratios increased over the ECT course in relation to treatment response. Modulation of frontal fE/I ratios may be an important mechanism of action of ECT.

Electroconvulsive therapy improves somatic symptoms before mood in patients with depression: A directed network analysis

BackgroundThe recent network perspective of depression conceptualizes depression as a dynamic network of causally related symptoms, that contrasts with the traditional view of depression as a discrete latent entity that causes all symptoms. Electroconvulsive therapy (ECT) is an effective treatment for severe depression, but little is known about the temporal trajectories of symptom improvement during a course of ECT. ObjectiveTo gain insight into the dynamics of depressive symptoms in individuals treated with ECT. MethodsThe Quick Inventory of Depressive Symptomatology (QIDS) was used to assess symptoms twice a week in 68 participants with a unipolar or bipolar depression treated with ECT, with an average of 12 assessments per participant. Dynamic time warping (DTW) was used to analyze individual time series data, which were subsequently aggregated to calculate a directed symptom network and the in- and out-strength for each symptom. ResultsParticipants had a mean age of 49.6 (SD = 12.8) and 60% were female. Somatic symptoms (e.g., decreased weight) and suicidal ideation showed the highest out-strength values, indicating that their improvement tended to precede improvements in mood symptoms, which showed high in-strength. Sad mood had the highest in-strength, and thus appeared to be the last symptom to improve during ECT treatment (p < 0.001). ConclusionThis study addresses a gap in the existing literature on ECT, by first analysing the temporal trajectories of symptoms within individual patients and subsequently aggregating them to the group level. The results show that somatic symptoms tend to improve before mood symptoms during ECT.

Etomidate versus propofol for electroconvulsive therapy: An intraindividual comparative study during the COVID-19 pandemic

ObjectivesThe Coronavirus disease 2019 (COVID-19) pandemic markedly influenced mental health care practices, notably regarding electroconvulsive therapy (ECT). This was due to the redistribution of anesthetic agents used during ECT such as propofol, for intensive care units. Because in our center propofol was switched to etomidate to avoid ECT activity discontinuation, we undertook this study in order to compare Propofol and Etomidate regarding electroencephalographic seizure duration and stimulus intensity. MethodsWe performed a retrospective and comparative study, each patient being its own control. We included patients with at least two courses of ECT on propofol and two others with etomidate over the period from September 2019 to April 2021, regardless of the psychiatric diagnosis. Our data collection process notably targeted stimulus intensity, seizure duration recorded using electroencephalography, and medication used for anesthetic induction. ResultsOverall, we included 18 patients with a male: female ratio of 1:2.6 and a mean (and standard deviation) age of 62.7±13.4 years. We found that the mean intensity of stimulation was significantly lower with etomidate when compared to propofol (425.3±250.0 vs. 658.9±280.2 mC, P=0.001). The mean duration of electroencephalographic seizure was significantly higher with etomidate in comparison to propofol (53.5±16.6 vs. 35.0±12.2seconds, P<0.001). ConclusionBy using each patient as its own control, our study found that etomidate, while compared to propofol, was related to a lower level of stimulatory intensity and a longer electroencephalographic seizure duration.