Long-term weekly continuation electroconvulsive therapy: a case series

Despite best efforts with continuation pharmacotherapy, many patients relapse after a successful course of electroconvulsive therapy (ECT). Although maintenance ECT can be a useful and cost-effective treatment modality, there is considerable heterogeneity on how it is used. The authors report a case series of 3 patients ages 68, 43, and 81 years with diagnosis of schizoaffective disorder, bipolar disorder, and major depression with psychotic features who required weekly ECT treatments for several years. All attempts to space treatments led to rapid decompensation. None of the patients experienced clinical evidence of any treatment related cognitive or physical morbidity.     

The treatment of psychotic depression in later life: a comparison of pharmacotherapy and ECT

Objective. Response to combination pharmacotherapy and to electroconvulsive therapy (ECT) was evaluated in elderly patients with psychotic depression. Method. Twenty-five patients, aged 60 years and older, with DSM-III-R unipolar psychotic major depression, were treated in an open, non-randomized fashion with either 6 weeks of nortriptyline and perphenazine (N=8) or ECT (N=17). Response was defined as a Hamilton score of ≤10 and the absence of delusions and hallucinations. Patients who failed to respond to combined antidepressant–antipsychotic medication underwent 2 weeks of lithium augmentation. Results. Two (25.0%) patients responded to the first 6 weeks of pharmacotherapy whereas 15 (88.2%) patients responded to ECT (Fisher's exact test, p=0.004). Even after lithium augmentation, there was a trend for patients to be less responsive to medication than to ECT (50.0% versus 88.2%, Fisher's exact test, p=0.059). Survival analysis, based on 8 weeks of observation, demonstrated that patients took longer to respond to pharmacotherapy than to ECT (mean (SE) of 7(0) weeks versus 4(0) weeks; log rank χ²=10.43, df=1, p=0.001). Conclusions. We found that elderly patients with psychotic depression had a significantly lower frequency of response to nortriptyline and perphenazine than to ECT. However, patients responded more slowly to pharmacotherapy than to ECT and longer duration of treatment may have improved the outcome of the medication group. These findings suggest the need for a randomized controlled trial comparing the efficacies of drug treatment and ECT in late life psychotic depression. © 1998 John Wiley & Sons, Ltd.     

A prospective naturalistic study of electroconvulsive therapy in late-life depression

We performed a prospective, naturalistic study using standardized clinical rating scales to characterize the effect of electroconvulsive therapy (ECT) on mood, cognition, and medical status in late-life depression. Over a 16-month period, 40 patients aged 60 years and over who fulfilled DSM-III criteria for a major depressive episode received a total of 42 ECT courses. Three patients (7%) developed significant medical complications: one had a syncopal episode due to arrhythmia, and two had symptomatic vertebral compression fractures. Confusion was noted during 13 courses (31%) and persisted at discharge in four (10%). More than half the patients were either psychotic or demented on admission, and all but three had been either unresponsive or intolerant to pharmacotherapy. All patients experienced a decrease in their depressive symptoms and more than two thirds were in complete or partial remission at discharge. Patients with psychotic depression experienced a greater improvement than patients with nonpsychotic depression, and patients with organic mental disorders experienced the same improvement as other patients. This study confirms that ECT is a safe and effective treatment of depression in late life.     

Psychotic and nonpsychotic depression: comparison of response to ECT

The charts of 46 patients who underwent ECT in a teaching hospital between 1980 and 1986 were reviewed. All patients were suffering from major depression, with or without psychotic features, and were resistant to pharmacotherapy. Response to ECT was compared between those with psychotic features (N = 27) and those without psychotic features (N = 19). Both groups had equal and effective response to ECT. Therefore, the presence of psychotic features was not significant in predicting response to ECT.     

Electroconvulsive therapy and mental retardation.

Reports on use of electroconvulsive therapy (ECT) in persons with mental retardation (MR) and mental illness are meager. We describe the successful use of ECT in the management of medication-resistant mental illness in persons with mental retardation. Details of the treatment of five patients with MR and psychotic disorders are reported. ECT was successful after the failure of adequate trials of traditional pharmacotherapy. Persons with MR did not have disproportionate adverse effects of ECT as a consequence of the MR. Four of the five cases reported received maintenance ECT. ECT should be considered in the affective and psychotic disorders occurring in persons with MR when traditional pharmacotherapy fails.     

Predicting efficacy of electroconvulsive therapy in major depressive disorder

The aim of this study was to investigate methods for predicting the efficacy of electroconvulsive therapy (ECT) in patients with major depressive disorder. Subjects comprised 24 inpatients with major depressive disorder diagnosed according to DSM-IV criteria who were resistant to antidepressant therapy or who, due to adverse reactions, could not undergo pharmacotherapy at adequate doses for sufficient durations. ECT was generally performed 12 times using a sinusoidal-wave device. Efficacy of ECT was evaluated using the 17-item Hamilton Rating Scale for Depression (HRSD). Multiple regression analysis was performed, using the final rate of improvement with ECT as the dependent variable, and improvement rate at completion of three ECT sessions and adequacy of pharmacotherapy before ECT as independent variables. Significant positive correlations were seen between final improvement rate with ECT and improvement rate at completion of three ECT sessions (partial correlation coefficient, 0.50, P<0.02), and significant negative correlations were seen between final improvement rate and adequacy of pharmacotherapy before ECT (partial correlation coefficient, -0.51, P<0.02). No significant differences were identified between responders and non-responders with respect to age, sex, duration of index episode, number of previous depressive episodes, whether depression was melancholia-type, whether depression was accompanied by psychotic features, total HRSD score immediately before ECT, and HRSD retardation or agitation scores. These results suggest that history of pharmacotherapy prior to ECT and improvement rate at completion of three ECT sessions may offer predictors for the final rate of improvement with ECT.     

One-year outcome of psychotic depression after successful electroconvulsive therapy

BACKGROUND: Psychotic depression is thought to have a higher relapse frequency after electroconvulsive therapy (ECT) compared with nonpsychotic depression, although this observation is contradicted by previous studies that have found the opposite. In this study, the 1-year risk of relapse after successful ECT was determined prospectively in patients with psychotic depression and compared with the risk of relapse observed for depressed patients without psychotic features. METHOD: Fifty-nine responders to ECT (a decrease in Hamilton Rating Scale for Depression [HAM-D] score > or = 50%) were followed for 1 year: 29 with and 30 without psychotic features. Relapse was defined as meeting DSM-IV criteria for major depressive disorder and a HAM-D score > or = 16. The frequency of relapse after 4 and 12 months was compared between both samples, adjusted for the co-variables duration of the index episode and type of post-ECT pharmacotherapy. RESULTS:: At both 4 and 12 months after ECT, instances of relapse were significantly lower in patients with psychotic depression compared with nonpsychotic patients: 3/28 (11%) versus 16/27 (59%) and 4/27 (15%) versus 19/28 (68%), respectively. CONCLUSIONS: The main finding of the present study is the favorable 1-year outcome for patients with psychotic depression after response to ECT with a trend toward the same result at 4 months. The 1-year outcome of the total sample is also more favorable than expected.     

BDNF blood levels after electroconvulsive therapy in patients with mood disorders: A systematic review and meta-analysis

Objectives. To evaluate whether electroconvulsive therapy (ECT), a very effective non-pharmacological treatment for mood disorders, induces neurotrophic effects, indexed by the measurement of peripheral brain-derived neurotrophic factor (BDNF) levels. Methods. Systematic review and meta-analysis of clinical trials published in PubMed/Medline from the first date available to October 2013. We included studies measuring pre- and post-BDNF blood levels under ECT in patients with mood disorders in the acute depressive episode. Results. Eleven studies (n = 221 subjects) were eligible. These studies enrolled subjects with unipolar, bipolar and psychotic depression and varied regarding electrode placement (unipolar vs. bipolar) and previous use of pharmacotherapy. Nonetheless, BDNF significantly increased after ECT (Hedges’ g pooled, random-effects model of 0.354; 95% CI = 0.162–0.546). The results were robust according to sensitivity analysis and Begg's funnel plot did not suggest publication bias. Meta-regression results did not show association of the outcome with any clinical and demographic variable, including depression improvement. Conclusions. Our meta-analysis indicates that, similar to pharmacological interventions, peripheral BDNF increases after ECT treatment. The lack of correlation between BDNF increasing and depression improvement suggests that ECT induces neurotrophic effects regardless of clinical response in depression.     

Electroconvulsive therapy for the treatment of neuroleptic malignant syndrome with psychotic symptoms: a report of five cases.

We report five cases of neuroleptic malignant syndrome (NMS) with psychotic symptoms treated with electroconvulsive therapy (ECT). Clinical response was observed after the first or the second session of ECT in every case, and the symptoms of NMS resolved by the third or fourth session. The mean time from the initial ECT to complete resolution was 6.0 days. No side effects from ECT were observed. Although the first treatment for NMS is pharmacotherapy using drugs such as dantrolene and bromocriptine, our results suggest that ECT is a useful therapeutic method for patients with NMS and psychotic symptoms.     

Use of modified electroconvulsive therapy in a case of polymyositis presenting with delusion of nihilism of proxy (Odysseus syndrome)

We present a case of psychotic depression with polymyositis presenting with the distinct phenomenon of nihilism by proxy, which was treated with electroconvulsive therapy (ECT). A female patient with polymyositis was initially treated with pharmacotherapy. After initial response, there was deterioration in her mental state and hence, after careful consideration, neurological, and anaesthetic consultations, modified ECT was given with close monitoring. The mental state of the patient improved with a course of ECT, which proceeded without any complications. Her depressive symptoms including the delusion of nihilism by proxy responded to ECT. To the best of our knowledge, the use of ECT has not been reported in a case of polymyositis before, and this case shows that modified ECT can be given successfully in patients with polymyositis.     

Combined use of lamotrigine and electroconvulsive therapy in bipolar depression: a case series

OBJECTIVE: Lamotrigine and electroconvulsive therapy (ECT) are both safe and effective treatments for bipolar depression. Concerns exist that anticonvulsants may interfere with seizure expression during ECT or may exacerbate cognitive side effects, potentially affecting clinical response. This report examines the clinical use of concurrent ECT and lamotrigine for acute bipolar depression and the transition to maintenance therapy. METHODS: Nine patients with acute bipolar depression were simultaneously treated with a course of ECT while titrating lamotrigine for maintenance therapy. We compared mean stimulus intensity, mean seizure duration, and mean time to orientation after treatment for each patient during treatment with their highest and lowest lamotrigine dose. RESULTS: All 9 patients were treated to remission. From the lowest daily dose to the highest daily dose, mean increase in lamotrigine was 102.8 mg. Clinically adequate seizures were obtained in each patient. Lamotrigine had minimal effect on each measured ECT parameter. The interval between ECT treatments was spaced to a mean of 15.2 days. The treatment combination was well tolerated, with no serious adverse events, no rashes, and no worsening of cognitive side effects. CONCLUSIONS: Concurrent use of lamotrigine with ECT in bipolar depression seems safe, did not interfere with routine ECT practice, and allowed for transition to maintenance pharmacotherapy.     

Enhanced attention-dependent auditory processing by electroconvulsive therapy in psychotic depression

There is a lack of knowledge about the effect of electroconvulsive therapy (ECT) on auditory event-related potentials (ERPs) in severe psychotic depression. The aim of this study was to investigate both the effect of ECT on attention-dependent ERP (P300) and the correlation of P300 values with depression level. We recorded the auditory ERPs of 23 patients expressing psychotic symptoms and fulfilling the DSM-III-R criteria for treatment-resistant severe major depressive episode before and a week after successful bitemporal ECT. The clinical status was assessed with Hamilton (Ham-D) and Montgomery and Asberg (MADRS) depression scales. ECT was clinically very effective with these scales. On the level of auditory processing, ECT increased P300 amplitude with no significant effect on latency. Small amplitudes over the left hemisphere before treatment were associated with bigger Ham-D-score decrement. ECT produces a significant increase in brain activity at the level of attention-dependent auditory processing in severe depression. The change in electrical responses seems to represent a largely independent variable from the clinical assessment scales, even if the recovery rate was remarkable, because the change in overall symptom scores did not correlate with the P300 changes.     

ECT and Anticoagulation

Electroconvulsive therapy (ECT) is an effective and safe treatment for depression. Anticoagulation therapy is used to reduce morbidity or mortality from stroke or recurrent pulmonary embolus in various cardiac and vascular conditions. We report in detail the successful ECT treatment of a patient suffering from major depression with psychotic features who continued warfarin (Coumadin) anticoagulant therapy.     

Medication resistance and clinical response to electroconvulsive therapy

We examined the extent to which medication resistance during an episode of major depression was related to short-term clinical response to bilateral electroconvulsive therapy (ECT). Strength of pharmacological treatment trials was rated in 53 patients who met Research Diagnostic Criteria for major depressive disorder and were subsequently treated with ECT. Patients who had failed to respond to adequate pre-ECT pharmacotherapy were substantially less likely to respond to ECT than patients who had not received adequate pharmacological trials before ECT. Therefore, medication resistance had predictive value with respect to the therapeutic effects of ECT. The clinical and theoretical implications of this finding are discussed.     

Factors Influencing Response to Bilateral Electroconvulsive Therapy in Major Depression

The records of 52 patients with major depression who were treated with bilateral electroconvulsive therapy (ECT) were reviewed. Responders and nonresponders were compared on demographic, clinical, and treatment parameters. ECT nonresponders had a longer duration of current depressive episode as well as a greater initial severity of depression. The groups did not differ in age, sex, polarity, presence of psychosis, pre-ECT pharmacotherapy, and treatment parameters other than total electrical charge administered. Patients with long episode duration and greater severity of illness may represent a subgroup of major depressives relatively refractory to ECT and warranting novel therapeutic approaches.     

The influence of concomitant antidepressant medication on safety, tolerability and clinical effectiveness of electroconvulsive therapy.

BACKGROUND: A major problem in the treatment of severe depression is the onset latency until clinical improvement. So far, electroconvulsive therapy (ECT) is the most effective somatic treatment of depression. This holds especially true for treatment-refractory disturbances. However, not all patients respond to conventional unilateral ECT. In certain cases, subsequent clinical response can be achieved using bilateral or high-dose unilateral ECT. Also, a concomitant pharmacotherapy can be utilized to augment therapeutic effectiveness. Surprisingly, data in this field are widely lacking and only few studies showed advantages of an ECT/tricyclic antidepressant combination. METHOD: We retrospectively evaluated 5482 treatments in 455 patients to investigate possible therapeutic advantages in combination therapies versus ECT monotherapy. Main outcome criteria were clinical effectiveness and tolerability. Moreover, treatment modalities and ictal neurophysiological parameters that might influence treatment outcome were analysed. RESULTS: A total of 18.2% of our treatments were ECT monotherapy, 8.87% were done with one antidepressant. Seizure duration was unaffected by the most antidepressants. SSRI caused a lengthened seizure activity. Postictal suppression was lower in mirtazapine and higher in SSRI and SNRI treated patients. A significant enhancement of therapeutic effectiveness could be seen in the patient group receiving tricyclics, SSRI or mirtazapine. Serious adverse events were not recorded. CONCLUSION: Our study supports the hypothesis that mirtazapine can be used to enhance the therapeutic effectiveness of ECT. Controlled studies are necessary to further investigate the possible advantages of ECT and pharmacotherapy combinations, especially the use of modern dually acting antidepressants which have proven their good effectiveness in treatment-resistant depression.     

The opposite effects of fluvoxamine and sertraline in the treatment of psychotic major depression: a case report

Background  

Psychotic major depression is a clinical subtype of major depressive disorder. A number of clinical studies have demonstrated the efficacy of the combination of an antidepressant (for example, a tricyclic antidepressant or selective serotonin reuptake inhibitor (SSRI)) and an atypical antipsychotic or electroconvulsive therapy (ECT) in treating psychotic major depression. In several studies, monotherapy of SSRIs such as fluvoxamine has been shown to be effective in the treatment of psychotic major depression.     

ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE.

OBJECTIVE: To compare the relative efficacy of electroconvulsive therapy (ECT) in psychotic and nonpsychotic patients with unipolar major depression. METHODS: The outcome of an acute ECT course in 253 patients with nonpsychotic (n = 176) and psychotic (n = 77) unipolar major depression was assessed in the first phase of an ongoing National Institute of Mental Health-supported four-hospital collaborative study of continuation treatments after successful ECT courses. ECT was administered with bilateral electrode placement at 50% above the titrated seizure threshold. The remission criteria were rigorous: a score 相似文献   

Differential response to combined treatment in patients with psychotic versus nonpsychotic major depression

Research has demonstrated that depressed patients with psychotic features show poorer outcomes when treated with pharmacotherapy alone compared with those without psychotic features. However, research has not investigated whether this differential response also applies to combined treatment that includes pharmacotherapy and psychotherapy. In the current study, data were pooled from two clinical trials in which patients diagnosed with major depressive disorder with or without psychotic features were treated with combined treatment. Although similar in severity at pretreatment, results indicated that patients with psychotic depression showed a poorer response in terms of depression severity at postoutpatient treatment and at 6-month follow-up compared with those with nonpsychotic depression. Following treatment, patients with psychotic depression were over four times as likely to exhibit high levels of depression and suicidal ideation. Current state-of-the-art combined treatments have poorer efficacy in depressed patients with psychotic symptoms, and adapted treatment approaches are needed.     

Electroconvulsive therapy in the treatment of depression in elderly

The use of a electroconvulsive therapy (ECT) in the elderly suffering from depression is still controversial in Poland. Not only psychiatrists but also specialists who qualify the patients for ECT--internal medicine specialists, neurologists and anaesthesiologists--treat the advanced age of a patient as a contraindication to ECT. It is also believed that ECT has adverse influence on the mental state of patients with the so-called psychoorganic syndrome. In most centres in Poland ECT is reserved for patients with drug-resistant depression and those in whom pharmacotherapy is contraindicated for any reason, such as pregnancy. Nevertheless the patients are carefully selected with respect to their physical condition. In many countries however the older the patient, the more likely he/she is to receive ECT as a method of choice. The effectiveness of this method in elderly patients is considered to be higher than in younger groups. ECT seems to be particularly effective in depression with psychotic symptoms and psychomotor retardation. The adverse effect of ECT on cognitive functions (learning and memory) which is a great concern of both doctors and patients, is actually noted in a small group of patients and usually transient. Moreover, the frequency of occurrence of this effect in elderly is not greater than in younger patients.