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PubMed1993

Electroconvulsive therapy.

Electroconvulsive therapy (ECT) is a safe, effective, valuable treatment for serious affective disorders (eg, major depression). Sometimes indicated for other, occasionally nonpsychiatric, medical conditions, ECT is a moderately complex procedure for which training is provided routinely during psychiatric residency. Although temporary confusion and amnesia are expected immediately after treatment, no reliable data suggest that permanent memory loss or cognitive deficit is caused by modern ECT. Indeed, because severe depression itself often causes both memory and cognitive deficits, ECT's remarkable therapeutic effectiveness is associated with long-term improvement in cognition, learning ability, and memory for many patients. Controversy over safety and effect on memory is fueled largely by public misinformation.

Adolescent↗
PubMed1996

Is postictal electrical silence a predictor of response to electroconvulsive therapy?

Electroconvulsive therapy (ECT) is an established effective treatment modality for patients with severe depression. Recent studies have focused on developing predictors of response. In this prospective study, using percent decrease in Hamilton Depression Scale (21 items) as the outcome measure, we blindly evaluated 33 inpatients with major depression to determine whether postictal suppression, the electrical silence following induced seizure, would predict treatment response to ECT. A significant relationship was observed between degree of postictal suppression and likelihood of clinical improvement. Postictal suppression should be explored in more controlled studies as a predictor of ECT response.

Brain↗
PubMed1986

Treatment delays in the course of electroconvulsive therapy.

Electroconvulsive therapy (ECT) is often delayed because the patient develops cognitive disturbances. The authors reviewed the charts of 45 depressed patients who received ECT and found that 25 patients developed cognitive dysfunctions severe enough to cause a delay in treatment. The development of organic symptoms causing delays in treatment was positively correlated with increased age and the presence of preexisting cognitive dysfunction, and the treatment delays led to longer periods of hospitalization. The authors emphasize the need for early identification of the causes of cognitive dysfunction after ECT and for careful selection of the treatment strategy for each patient to reduce the risk of adverse effects.

Age Factors↗
PubMed1979

Succinylcholine drug interactions during electroconvulsive therapy.

Electroconvulsive therapy (ECT) is frequently described as being almost free of absolute contraindications. However, drug interactions with succinylcholine pose potential hazards to which this paper calls attention. In addition to its neuromuscular-blocking action, succinylcholine has other acetylcholine-like effects. Drugs which inhibit cholinesterase activity or which inhibit acetylcholine release or synthesis may produce prolonged respiratory paralysis when combined with succinylcholine. The increasing longevity of the population receiving chemotherapy for physical ailments implies that greater numbers of these patients may also become candidates for ECT and therefore be at risk for adverse drug interactions with succinylcholine. Of particular importance to the psychiatrist are the various psychotropic drugs that have been reported to interact with succinylcholine. Precautions in using drug combinations and treatment of complications are described.

Animals↗
PubMed1994

Patient attitudes toward electroconvulsive therapy.

Electroconvulsive therapy (ECT), a safe and effective treatment for major depression, has been more harshly criticized than any other psychiatric treatment. Despite widespread negative public opinion, clinical impressions that are supported by limited empirical data suggest that patients who benefit from ECT do not share these negative sentiments. This study surveyed attitudes toward ECT in 78 depressed inpatients, twice during hospitalization and at 6 months after discharge, using a semi-structured interview. Significantly more ECT-treated patients (n = 56) were favorable about ECT, compared to depressed patients (n = 22) never treated with ECT, both at pretreatment (chi square = 8.4, df = 1, p < .01) and at post-treatment (chi square = 12.5, df = 1, p < .01). Favorable attitudes were maintained after 6 months. ECT-treated patients, initially uncertain or negative about ECT, changed to a favorable attitude after completing treatment. Ninety-eight percent of ECT-treated patients said they would agree to ECT if they became depressed again.

Adult↗
PubMed1999

Aminophylline increases seizure length during electroconvulsive therapy.

Electroconvulsive therapy (ECT) is considered to be one of the most effective treatments for patients with major depression and persistent psychosis. Seizure characteristics probably determine the therapeutic effect of ECT; as a consequence, short seizures are accepted as one of the factors of poor outcome. During most ECT courses seizure threshold increases and seizure duration decreases. Methylxanthine preparations, caffeine, and theophylline have been used to prolong seizure duration. The use of aminophylline, more readily available than caffeine, has not been well documented. The objective of this study was to test the effects of aminophylline on seizure length. Fourteen drug-free patients with diagnoses of affective disorder or psychotic episode receiving ECT participated in this study. Seizure length was assessed clinically and per EEG. Statistical comparisons were done using paired t tests. A significant increase (p < 0.04) in seizure length was achieved and maintained on three subsequent treatments with aminophylline. No adverse events were noted from the addition of aminophylline.

Adult↗
PubMed2004

[Anaesthesia in electroconvulsive therapy].

Electroconvulsive therapy (ECT) is a safe and efficient procedure performed for the treatment of drug resistant depression and other psychiatric disorders. Nowadays, its administration under general anaesthesia is a worldwide process. Anaesthetic management generally involves a short acting barbiturate such as thiopental in induction followed by a muscle relaxant. Succinylcholine is the drug of choice for muscle relaxation. This approach prevents patients from suffering hazardous orthopaedic injuries due to confusion. The effectiveness of ECT depends on an adequate seizure, and so the anaesthetist should be aware of the factors that influence the duration of seizures as well as concomitant diseases and potential adverse antidepressive drug reactions. An acute haemodynamic response due to sympathetic discharge in the course of the seizure provokes abrupt cardiovascular and cerebrovascular changes such as bradycardia, tachycardia, hypertension and raised intracranial pressure. The control of responses by b-blockers and similar agents is especially important in patients with cardiac or intracerebral problems. ECT is applicable in nearly all age groups and even in pregnant subjects. The aim of this article is to review the aspects of anaesthetic management of safe and effective ECT.

Anesthesia↗
PubMed2000

No evident neuronal damage after electroconvulsive therapy.

Electroconvulsive therapy (ECT) is regarded as one of the most effective treatments for major depressive disorder but has also been associated with cognitive deficits possibly reflecting brain damage. The aim of this study was therefore to evaluate whether ECT induces cerebral damage as reflected by different biochemical measures. The concentrations in the cerebrospinal fluid (CSF) of three established markers of neuronal/glial degeneration, tau protein (tau), neurofilament (NFL) and S-100 beta protein, were determined in nine patients who fulfilled DSM-IV criteria for major depression. CSF samples were collected before and after a course of six ECT sessions. The CSF/serum (S) albumin ratio reflecting potential blood-brain barrier (BBB) dysfunction was also determined at these time points. The treatment was clinically successful with a significant decline of depressive symptoms in all patients as assessed by the Montgomery-Asberg Rating Scale for Depression. Several patients had signs of BBB dysfunction and/or neuronal damage before the start of treatment. Levels of CSF-tau, CSF-NFL and CSF-S-100 beta levels were not significantly changed by ECT. Also the CSF/S albumin ratio was found to be unchanged after the course of ECT. In conclusion, no biochemical evidence of neuronal/glial damage or BBB dysfunction could be demonstrated following a therapeutic course of ECT.

Adult↗
PubMed2004

Adjustment of anaesthesia depth using bispectral index prolongs seizure duration in electroconvulsive therapy.

Electroconvulsive therapy (ECT) under propofol anaesthesia induces relatively shorter seizures compared to barbiturate anaesthesia. Since significant correlation between seizure duration and bispectral index (BIS) value immediately before electrical stimulus has been reported among patients, adjustment of anaesthesia depth as determined by BIS may be effective in obtaining a longer seizure length. In the present study, we examined this hypothesis in those patients whose muscular seizure duration was less than 40s. ECT was prescribed to 20 patients suffering from endogenous depression. General anaesthesia was induced with propofol 1 mg/kg. Succinylcholine chloride 1 mg/kg was then given. The efficacy of electrical stimulation was determined using a tourniquet technique, electromyogram, and electroencephalography. When a patient had a seizure less than 40s in their second ECT treatment, the subsequent treatment was modified such that the electrical stimulus was given after waiting for a higher BIS value (+10-20). Intensity of electrical stimulus and anaesthesia conditions were identical in the two treatments. All 20 patients had longer seizures as determined by the electromyogram and/or electroencephalography when the stimulus was delivered at the higher BIS value. Seizure duration measured by muscle movement was 31+/-5 s when the stimulus was delivered without waiting and 46+/-10 s when delivered after waiting. There was a significant difference in seizure duration between the two treatments (P<0.01). Waiting for a recovery in BIS value before electrical stimulation can prolong seizure duration.

Adult↗
PubMed2005

Guide to anaesthetic selection for electroconvulsive therapy.

Electroconvulsive therapy (ECT) is used in the treatment of severe psychiatric disorders. It involves the induction of a seizure for therapeutic purposes by the administration of a variable-frequency electrical stimulus via electrodes applied to the scalp. The original application of ECT in non-anaesthetised patients resulted in many traumatic effects and was replaced, in the early 1960s, with a modified ECT regimen that used anaesthesia with neuromuscular blockade. This remains the worldwide standard today. The development of modern ECT devices, with improved impulse modes, has also reduced the incidence of post-interventional cognitive adverse effects. The variety of centrally-acting co-medications administered and the cardiovascular effects occurring during the procedure make patients receiving ECT a challenge for the anaesthetist. The efficacy of ECT depends on the production of adequate seizures; however, the anaesthetic agents commonly used during ECT suppress the generation of convulsions. Therefore, the efficacy of ECT requires knowledge of anaesthetic precepts, understanding of the interaction between anaesthetic drugs and seizure activity, and awareness of the physiological effects of ECT as well as the treatment of those effects. Successful and safe ECT depends on the correct choice of anaesthetic drugs for the individual patient, which have to be chosen with respect to the individual concomitant medication and pre-existing diseases. This review provides information for the optimal selection, set-up and practice of anaesthetic drug treatment in ECT.

Anesthetics↗
PubMed1997

The effect of esmolol on ST-segment depression and arrhythmias after electroconvulsive therapy.

Electroconvulsive therapy (ECT) induces sympathetically mediated hemodynamic alterations that can be associated with myocardial ischemia and arrhythmia generation. Esmolol, a short-acting beta-blocker, blunts the hypertension and tachycardia seen with ECT. The purpose of this study is to determine whether esmolol use during ECT reduces the incidence of myocardial ischemia or arrhythmias after ECT. In a randomized, double-blind, placebo-controlled protocol, with each patient acting as his/her own control, the effects of esmolol on the incidence of myocardial ischemia and arrhythmias were studied using two-lead Holter monitoring for at least 2 h post-ECT. Nineteen patients underwent 71 ECT treatments (34 placebo, 37 esmolol), recording 746 h of Holter data. The esmolol group had significantly reduced heart rate and mean arterial pressure immediately after ECT. There was no difference in the incidence of ECG defined ischemia post-ECT between groups, with 7 of 19 (36.8%) patients in the esmolol group showing ST-segment depression compared with 5 of 19 (26.3%) in the placebo group. There was no difference between groups in arrhythmia detection. This experiment demonstrates that (a) ECT is associated with a significant incidence of ST-segment depression, (b) esmolol blunts the sympathetic discharge during ECT, and (c) esmolol does not reduce the incidence of post-ECT ischemia or arrhythmia.

Adrenergic beta-Antagonists↗
PubMed1996

The effect of esmolol pretreatment on the incidence of regional wall motion abnormalities during electroconvulsive therapy.

Electroconvulsive therapy (ECT) is associated with dramatic increases in arterial blood pressure and heart rate (HR) that may precipitate new left ventricular regional wall motion abnormalities (RWMAs) suggestive of myocardial ischemia. The purpose of this study was to investigate the effect of pretreatment with esmolol on the incidence of RWMAs after ECT. Thirteen patients served as their own controls and, in a random fashion, received a standard succinylcholine/methohexital anesthetic for one of two ECT sessions, and an identical anesthetic with esmolol 1 mg/kg for their other ECT session. Systolic (SBP), diastolic (DBP), mean arterial pressures (MAP) and HR were recorded after drug administration and before ECT and at 1-, 2-, 4-, 5-, 10-, and 15-min intervals after ECT. Echocardiograms were obtained at baseline, after drug administration, 1 min after ECT, and at recovery 15 min later. All patients had significant increases in SBP, DBP, and MAP at 1, 2 and 4 min after ECT versus baseline, whereas HR was significantly faster at all times in the control sessions. HR was significantly slower after anesthetic induction until 2 min after ECT in the esmolol versus the control group (P < 0.05). New RWMAs were seen in only 1 of 26 (4%) ECT sessions, despite the presence of baseline RWMAs in 31% of the patients. We conclude that contrary to previously reported data, new RWMAs after ECT are uncommon. Consequently, this study was unable to demonstrate any beneficial effect of pretreatment with esmolol on the incidence of ECT-induced RWMAs.

Adrenergic beta-Antagonists↗
PubMed2002

Relationships between seizure duration and seizure threshold and stimulus dosage at electroconvulsive therapy: implications for electroconvulsive therapy practice.

Recent studies cast doubt on the usefulness of seizure duration as an index for stimulus dosage adjustment at electroconvulsive therapy (ECT). A retrospective analysis on the relationships between seizure duration and seizure threshold and stimulus dosage was performed for 54 patients who received a standardized ECT dose titration and treatment protocol. Subjects receiving stimulus dosage at seizure threshold had a highly variable motor seizure duration, ranging from 15 to 89 s, and 7.4% of subjects had seizures longer than 60 s. Regression analysis showed that initial seizure threshold and height were independent predictors of motor seizure duration during dose titration and accounted for 34% of its variance. Stimulus dosage was increased by 40-67% between the first and second ECT session; however, 60% of subjects had no lengthening of seizures and motor seizure duration was significantly shorter at the second treatment (mean +/- SD: 35.7 +/- 12.3 vs 31.0 +/- 10.6 s; paired t = 2.9, d.f. = 34, P = 0.006). At the first and second ECT treatment, motor seizure duration was significantly related to stimulus dosage (r = -0.45 and r = -0.41, respectively). Given the negative correlation between seizure duration and stimulus intensity, a policy that recommends an increase of stimulus dosage and its reduction for patients with short and long seizures, respectively, does not necessarily result in 'optimal' seizure duration. A better dosing policy that places less emphasis on seizure duration is proposed.

Adolescent↗
PubMed2002

A randomized comparison of high-charge right unilateral electroconvulsive therapy and bilateral electroconvulsive therapy in older depressed patients who failed to respond to 5 to 8 moderate-charge right unilateral treatments.

BACKGROUND: Electroconvulsive therapy (ECT) is the treatment of choice in some older patients with severe depression. When compared with younger depressed patients, older patients have been shown to be as likely to respond to ECT but more likely to develop cognitive impairment. This study addresses whether adults aged 50 years and over who have already failed to respond to at least 5 moderate-charge right unilateral (RUL) ECT treatments (150% above seizure threshold) are more likely to benefit from a switch to high-charge RUL ECT (450% above threshold) or to bilateral (BL) ECT. METHOD: Twenty-four patients who were treated with 5 to 8 moderate-charge RUL ECT treatments and who failed to improve sufficiently were randomly assigned to receive either BL ECT (N = 11) or high-charge RUL ECT (N = 13). Depressive (24-item Hamilton Rating Scale for Depression) and cognitive scores (Mini-Mental State Examination [MMSE]) were compared under double-blind conditions at 3 phases of treatment. RESULTS: Patients in the BL ECT group exhibited significantly greater cognitive impairment (mean MMSE score decrease of 1.13) than those receiving high-charge RUL ECT (mean MMSE increase of 1.71). There were no statistically significant differences in clinical response to BL or high-charge RUL ECT (63.6% and 61.5%, respectively) or in depressive symptom remission (18.1% and 46.2%). CONCLUSION: These results suggest that older patients who fail to respond to moderate-charge RUL ECT may benefit from a switch to high-charge RUL ECT rather than BL ECT. Larger future studies will be needed to compare clinical response in patients switched from moderate-dose RUL ECT to higher-dose RUL or to BL ECT.

Aged↗
PubMed2000

Minimizing the cognitive effects of lithium therapy and electroconvulsive therapy using thyroid hormone.

Although electroconvulsive therapy (ECT) and lithium are effective treatments for mood disorders, they are both associated with cognitive side-effects that reduce patient compliance and satisfaction. Because both ECT and lithium have significant impact on the hypothalamic-pituitary-thyroid (HPT) axis, at least some of these side-effects may be associated with alterations in HPT activity. There is evidence that cognitive deficits in patients with bipolar disorder taking lithium are related to diminished thyroid status, but not to serum lithium level. A preliminary study showed that adjunctive use of thyroid hormone significantly improves cognitive functioning in patients taking lithium. An animal study and two double-blind, placebo-controlled clinical studies examining the adjunctive use of thyroid hormone (T3) and ECT have confirmed that T3 significantly protects against ECT-related memory impairment compared to placebo. Taken as a whole, this research suggests that adjunctive use of thyroid hormone has the potential to reduce cognitive side-effects of these important psychiatric treatments.

Journal Article↗
PubMed2004

Electroconvulsive therapy dosage in continuation/maintenance electroconvulsive therapy: when is a new threshold titration necessary?

Treatment effects and side effects of electroconvulsive therapy (ECT) depend on the level of applied energy in relation to the individual patient's seizure threshold. The threshold is known to increase during a course of frequently repeated ECT treatments and to return to baseline 6 months after cessation of treatment. In continuation ECT, however, as well as after early relapses, the interval between treatments is often longer than a few days but shorter than 6 months. Seizure thresholds for such cases have not been examined. We retrospectively examined 19 patients who had undergone repeated ECT treatments that had been separated by intervals of at least 14 days. We found significant changes in seizure duration, as measured by EEG and the cuff technique, when treatments were separated by durations exceeding 60 days. This is compatible with a decrease in seizure threshold or a loss of anticonvulsant action after 2 months and indicates the necessity to retitrate seizure threshold after this time.

Depressive Disorder↗