Use Of Electroconvulsive Therapy In Patients Research Articles

A Case Series of Noncatatonic Mutism with Poor Response to Conventional Treatment Approach

Abstract Mutism is the absence or marked paucity of verbal output due to functional or organic causes. Selective mutism is commonly seen in children with anxiety disorder. In psychiatric literature, long-standing mutism is most commonly associated with catatonic syndrome in adults. Although less commonly reported, long-standing mutism has also been associated with noncatatonic schizophrenia and posits a treatment challenge. Here, we describe two cases of long-standing noncatatonic mutism secondary to Schneiderian first rank symptoms, which were poorly responsive to conventional antipsychotic treatment and had good response to the combination of antipsychotics and electroconvulsive therapy (ECT). ECT is an underutilized treatment modality in patients with schizophrenia and is usually limited to catatonic states. The case series, thus, highlights the need for the development of an evidence base for the use of ECT in patients with noncatatonic mutism.

Case Report: Multiple Courses of Electroconvulsive Therapy for Treatment Resistant Depression in a 68 year old male with a Cardiac Resynchronization Therapy Device with Defibrillator

<h3>Introduction</h3> Background: Electroconvulsive therapy (ECT) has been safely and successfully applied in patients with cardiac pacemakers and implantable cardiac devices, and reviewed in a number of case reports (1, 2). Cardiac Resynchronization Therapy Devices (CRT-D), available with and without defibrillation, benefit patients with Heart Failure with reduced ejection fraction (HfreF) by improving left ventricular function, optimizing ventricular filling, and confers benefits in quality of life and mortality (3). There are currently no case reports on the use of ECT in patients with cardiac resynchronization therapy devices. <h3>Methods</h3> Methods: Patient is a 68-year-old male with a history of major depressive disorder, PTSD, cluster B personality traits who presented in December 2019 for suicidal ideation in the context of a major depressive episode. His medical history is notable for atrial fibrillation on warfarin, DM2 on insulin, non-ischemic cardiomyopathy with HFREF. In 2015, patient's Implantable cardioverter-defribillator (ICD) was replaced with CRT-D. He has a history of 4 previous suicide attempts, most recently four years ago as well as a history of self-injurious behavior. His suicidal ideation on this admission was notable for newly observed command auditory hallucinations telling him to harm himself, suggestive of a mood-congruent psychosis. Patient was started on low-dose risperidone. His other psychotropic medications included bupropion, venlafaxine, and gabapentin with multiple failed medication trials in the past. Patient's initial MADRS was 30 on admission scoring highly for suicidal ideation. After initiation of risperidone, patient's MADRS lowered to 16 prior to first ECT session. Prior to ECT, anesthesia, cardiology, and electrophysiology were consulted. Patient's CRT-D device was interrogated and determined to be functioning and patient was medically optimized for ECT from cardiology standpoint. His ejection fraction was 30% approximately 6 months earlier. Anesthesia expressed concern about management of sympathetic and parasympathetic response to ECT. <h3>Results</h3> Results: Prior to first session, Electrophysiology reprogrammed device and patient had defibrillator pads placed. A brief seizure was achieved. Due to no observed bradycardia after first session, the electrophysiologist recommended patient can undergo further ECT with placement of magnet on CRT-D to disable defibrillator. For the following 3 sessions, an adequate seizure was obtained. Patient reported robust response with MADRS of 6 reported prior to his second session. During ECT therapy, patient underwent echocardiogram which indicated ejection fraction of 20-25%. Cardiology was again consulted and felt patient could continue with ECT if euvolemic and asymptomatic. After 4^th session, a collaborative decision was made with patient to forego further ECT given patient's improvement in mood. Patient returned for another course of 3 sessions of ECT 8 months later and one maintenance session 9 months later. For these sessions, a magnet was used exclusively to disable fibrillator with robust effect on depressive symptoms. <h3>Conclusions</h3> Conclusion: This case indicates ECT can be provided safely to patients with a CRT-D device over an extended period of time; placing device in electrocautery mode with defibrillator pads as well as disabling defibrillator function with a magnet both proved effective methods to provide ECT safely. Further study of ECT in patients with CRT is warranted, in particular, to observe patients who complete a number of sessions more typical in treatment resistant depression. ECT in patients with CRT-P devices have not been reported. <h3>This research was funded by</h3> none

The Use of ECT in a Geriatric Patient with a Deep Brain Stimulator

<h3>Introduction</h3> Electroconvulsive therapy (ECT) is a commonly used and effective treatment for major depressive disorder with psychosis, especially in the geriatric population. Depressive disorders have significant prevalence in those with movement disorders including Parkinson's disease. Deep-brain stimulators are an effective treatment for Parkinson's disease, however, few cases in the literature exist about the use of ECT in patients with deep-brain stimulators. <h3>Methods</h3> A 68-year-old man with Parkinson's disease with a deep-brain stimulator (DBS) is seen in an outpatient geriatric psychiatry clinic. He has severe major depressive disorder with psychosis. The patient's clinical features include depressed mood, hopelessness, anhedonia, poor sleep, and poor appetite with weight loss. He endorses delusions of worsening physical and functional ability as well as delusions of abandonment and impoverishment. The patient experienced suicidal thinking and had impulsive para-suicidal behavior. The patient's symptoms are minimally responsive to treatment with antidepressants (Escitalopram, Mirtazapine, and Duloxetine) as well as psychotherapy. The patient's Parkinson's disease is treated with carbidopa-levodopa and a St. Jude DBS in his subthalamic nucleus, which was placed almost two years earlier. An ECT consultation was pursued in conjunction with discussion with the patient's neurologist. The patient begins undergoing acute bifrontal ECT with his DBS switched off for his treatments. <h3>Results</h3> The patient has, thus far, had 12 bifrontal acute phase ECT treatments, with the first 10 treatments occurring biweekly and then weekly. He is tolerating ECT well with minimal cognitive impairment immediately after the treatment and no complications relating to his DBS. After three treatments, the patient began experiencing significant improvements in mood, appetite, and sleep noted by himself and collateral sources. After 10 treatments the patient's suicidality and psychotic symptoms had resolved. The patient is much more active and has an improved level of functioning. His family notes that after over a year of severe depression, he finally is "back to himself." <h3>Conclusions</h3> ECT is an appropriate and effective treatment for major depressive disorder with psychosis in patients with concomitant Parkinson's disease who have a DBS. Although there are very few case reports of prescribing ECT to treat patients with Parkinson's disease that have a DBS device, this case demonstrates that it is a safe and efficacious treatment that should be considered. It is especially important to consider this treatment if there is a lack of response to antidepressants. When patients with DBS are not offered ECT due to reluctance and safety concerns, these patients are deprived of a valuable treatment option. <h3>Funding</h3> Not applicable

Electroconvulsive therapy and risk of dementia in patients with affective disorders: a cohort study

Electroconvulsive therapy (ECT) is the most effective treatment for severe episodes of mood disorders. Temporary memory loss is a common side-effect, but ongoing discussions exist regarding potential long-term adverse cognitive outcomes. Only a few studies have examined the frequency of dementia in patients after ECT. The aim of this study was to examine the association between ECT and risk of subsequent dementia in patients with a first-time hospital diagnosis of affective disorder. We did a cohort study of patients aged 10 years and older in Denmark with a first-time hospital contact for an affective disorder from Jan 1, 2005, through Dec 31, 2015, identified in the Danish National Patient Registry with ICD-10 codes F30.0 to F39.9. From the registry we retrieved information on all ECTs registered for patients and followed up patients for incidental dementia (defined by hospital discharge diagnoses or acetylcholinesterase inhibitor use) until Oct 31, 2016. We examined the association between ECT and dementia using Cox regression analyses with multiple adjustments and propensity-score matching on sociodemographic and clinical variables. Of 168 015 patients included in the study, 5901 (3·5%) patients had at least one ECT. During the median follow-up of 4·9 years (IQR 2·4-7·8) and 872 874 person years, the number of patients who developed dementia was 111 (0·1%) of 99 045 patients aged 10-49 years, 965 (2·7%) of 35 945 aged 50-69 years, and 4128 (12·5%) of 33 025 aged 70-108 years. 217 (3·6%) of the 5901 patients treated with ECT developed dementia, whereas of 162 114 patients not treated with ECT 4987 (3·1%) developed dementia. The corresponding incidences were 70·4 cases per 10 000 person-years (95% CI 61·6-80·5) and 59·2 per 10 000 person-years (57·6-60·8). In patients younger than 50 years and 50-69 years, ECT was not associated with a risk of dementia compared with age-matched patients who were not given ECT (age-adjusted hazard ratio [HR] 1·51, 95% CI 0·67-3·46, p=0·32; and 1·15, 0·91-1·47, p=0·22, respectively). In patients aged 70 years and older, ECT was associated with a decreased rate of dementia (0·68, 95% CI 0·58-0·80; p<0·0001), but in the propensity-score matched sample the HR was attenuated (0·77, 0·59-1·00; p=0·062). 31 754 patients (17·6%) died during follow-up (mortality rate per 1000 person-years 35·7, 95% CI 35·3-36·2) and supplementary analyses suggested that the risk of dementia, taking the competing mortality risk into account, was not significantly associated with ECT (subdistribution HR 0·98, 95% CI 0·76-1·26; p=0·24). ECT was not associated with risk of incidental dementia in patients with affective disorders after correcting for the potential effect of patient selection or competing mortality. The findings from this study support the continued use of ECT in patients with severe episodes of mood disorders, including those who are elderly. Danish Council for Independent Research, Danish Medical Research Council, the Velux Foundation, the Jascha Foundation, and the Doctor Sofus Carl Emil Friis and Olga Doris Friis grant.

Clinical Practice Guidelines for Management of Schizophrenia.

Clinical Practice Guidelines for Management of Schizophrenia.

Successful Use of Right Unilateral ECT for Catatonia

Catatonia is a neuropsychiatric syndrome involving motor signs in association with disorders of mood, behavior, or thought. Bitemporal electrode placement electroconvulsive therapy (ECT) is a proven effective treatment for catatonia, and this mode of ECT delivery is the preferred method of treatment in this condition. Studies in major depressive disorder have demonstrated that suprathreshold, nondominant (right) hemisphere, unilateral electrode placement ECT has fewer adverse effects, especially cognitive adverse effects, than bitemporal ECT. This case series describes the use of right unilateral (RUL) ECT in 5 patients with catatonia. Before ECT, all 5 patients in this series initially failed therapy with benzodiazepines and psychotropic medications. Each catatonic patient received a series of 8 to 12 RUL ECT in an every-other-day series. After ECT, 4 of the 5 patients had a full recovery from catatonia. One patient achieved only partial response to RUL ECT, and no additional benefit was obtained with bitemporal ECT. All patients in this case series tolerated RUL ECT without major adverse effects. This case series illustrates successful use of RUL ECT in patients with catatonia and adds to the early literature demonstrating its effective use in treating this complex condition.

Transient Febrile Reaction After Electroconvulsive Therapy (ECT) in a Young Adult With Intellectual Disability and Bipolar Disorder

We report the case of a 27-year-old man with mild-moderate intellectual disability (ID) and bipolar disorder treated with electroconvulsive therapy (ECT). He was psychiatrically hospitalized for agitation, aggression, and manic symptoms including insomnia, rapid and pressured speech, and hyperactivity. After multiple medication trials, ECT was recommended. The treatment was delayed owing to the need to obtain evaluation for incapacity and then substituted consent from the patient's mother. He received 2 ECT treatments with marked improvement but complicated by transient fevers, which resolved without treatment. Fever workup was unremarkable. The patient became calm and cooperative and was discharged home. He was readmitted 3 weeks later, again in an agitated manic state. He received 5 additional ECT treatments, but this time with no post-ECT fevers. Once again, his manic symptoms resolved, and he was safely discharged. Whereas patients with ID pose special challenges, our case is in keeping with the previous literature, which supports the use of ECT in patients with ID and comorbid psychiatric disorders.

Electroconvulsive Therapy in Patients With Skull Defects or Metallic Implants

Head injury is often associated with psychiatric morbidity. While it is well understood that the loss of critical areas of the brain may play a role in cognitive dysfunction and change in personality, head injury can also have profound effects on mood and cognition. The role of medications in the treatment of mood disorders associated with brain injury is well documented, and there is also evidence favoring the use of electroconvulsive therapy (ECT) in this context. However, data are limited on the use of ECT in patients with skull defects or metallic head implants. First, a review of the literature on use of ECT in patients with metallic head implants is provided. Electronic databases and online sites, including PubMed, Cochrane Library of Systematic Reviews, and UpToDate, were used to search for relevant articles and case reports on the use of ECT in patients with and without metallic implants in the head (1964 to 2009). The search terms electroconvulsive, electroconvulsive therapy, ECT, electroshock therapy, EST, head injury, brain injury, metallic plates, metallic implants, skull prosthesis, and depression were used interchangeably. The search produced 7 articles discussing exclusively the use of ECT in patients with a metallic skull plate. Second, the case of the successful and safe use of ECT in an individual with a previous history of brain trauma and metallic plate implantation is described. Most cases of head injury are managed by neurologists and rehabilitation consultants; the more severe cases of depression and other mood disorders tend to be referred for specialist psychiatric care. With greater degrees of deficit following head injury, management becomes more complicated. Our patient showed positive results with ECT, including improvement in depressive features and resolution of suicidal ideas/plans. ECT is an effective and safe alternative in patients with a history of brain trauma and metallic plate implantation who subsequently develop treatment-resistant depression and associated suicidal ideas or plans refractory to management with medications.

Use of ECT in patients with an intellectual disability: review

Aims and methodThe literature on the use of electroconvulsive therapy (ECT) in patients with an intellectual disability is scarce, despite a higher prevalence of psychiatric disorders than in the general adult population. We carried out a review of articles published before March 2010. All age ranges, severity of disability and diagnoses were included.ResultsWe found 72 case reports, a retrospective chart review study and other reviews, but no controlled studies. Most patients (79%) showed a positive outcome following ECT. Complications were seen only in 13% and there were no reports of cognitive decline. Many patients relapsed following ECT (32%) and the majority were maintained with medication at follow-up (71%).Clinical implicationsElectroconvulsive therapy is a valuable treatment for this patient group and should be considered earlier as opposed to as a last resort. Obstacles to its use include diagnostic difficulties, ethical and legal issues, a lack of objective measurements and uncertainty about its safety in this population.

Successful Electroconvulsive Therapy in a Patient With Intellectual Disability and Bipolar Disorder, With Catatonic Features Misdiagnosed as Encephalopathy

We describe the successful use of electroconvulsive therapy (ECT) in a 39-year-old woman with a complex clinical picture including bipolar disorder with catatonic features superimposed on a history of multiple congenital anomalies and intellectual and developmental disabilities. At age 34, the patient presented with marked regression and behavioral disturbance diagnosed as encephalopathy. Multiple medical evaluations were inconclusive, and treatment courses with antibiotics and steroids failed. After psychiatric evaluation, her condition was diagnosed as bipolar disorder with catatonic features. She was treated with ECT with dramatic improvement and resumption of her premorbid level of functioning. We discuss the relevant literature on the use of ECT in patients with intellectual disability.

Electroconvulsive Therapy in Myasthenia Gravis

Myasthenia gravis (MG) is a neuromuscular disease sometimes associated with severe psychiatric complications. The use of electroconvulsive therapy (ECT) in MG raises certain challenges. We describe a patient with MG and a steroid-induced major depressive episode with psychotic features treated with ECT. We also review the literature on similar cases and on the safety of ECT with muscle relaxation in this condition. The use of ECT in patients with MG is a viable therapeutic option when psychiatric complications secondary to MG or its treatment do not respond to psychotropic medications. ECT with muscle relaxants could be administered safely, with appropriate precautions kept in mind.

A pilot survey of geriatric psychiatrists' views on the use of electroconvulsive therapy in fractures

Psychiatrists are cautious in administering electroconvulsive therapy (ECT) to patients with fractures and bony disease for fear of complications. Drawing on the collective experience of geriatric psychiatrists may allow a better understanding of the use of ECT in fractures. The views of all consultant geriatric psychiatrists in west London on the use of ECT in patients with fractures were acquired by a questionnaire survey based on two fictitious case vignettes. Most geriatric psychiatrists would use ECT in the two cases. Moreover, they would almost always seek specialist advice from orthopaedic surgeons and anaesthetists before and during the course of ECT. These findings were consistent with the existing anecdotal literature of case-reports. As individual geriatric psychiatrists and general psychiatrists are likely to see only a few patients with fractures requiring ECT, randomized and controlled studies of efficacy and side effects are not possible. A questionnaire survey of a larger multi-centre sample of geriatric psychiatrists and general psychiatrists can build on this pilot study by using a modified questionnaire to provide more detailed and clinically relevant information. Copyright © 2000 Whurr Publishers Ltd.

ECT in the treatment of patients with neurological and somatic disease.

An evaluation of the safety and efficacy of electroconvulsive therapy (ECT), for the treatment of patients with severe medical and neurological illness, was undertaken. The English-language literature reporting the use of ECT in patients with neurological and somatic disease was reviewed. This review included reports describing ECT used for the treatment of affective disturbances and catatonia in patients with concurrent neurological or somatic disease, as well as reports dealing with the efficacy of ECT for the treatment of certain neurological conditions for which it has been reported to have some benefit independent of its psychiatric effect. ECT is safe and effective for the treatment of affective and catatonic disorders in patients with most neurological and medical diseases, including elderly and debilitated patients with multiple illnesses, if the specific medical risks are carefully evaluated in each case, and appropriate modifications of technique are used to reduce the risk of potential complications. Apart from its use in psychiatry, ECT has been reported to have therapeutic effects in Parkinson's disease, neuroleptic malignant syndrome, aggressive behavioral disorders following brain injury, certain forms of epilepsy, and some forms of delirium due to toxic or metabolic encephalopathies. The potential for ECT to play an active role in the clinical management of patients with these disorders, many of whom are presently refractory to maximal medical treatment, should be evaluated by systematic studies.