Discrepancy between opinion and attitude on the practice of ECT by psychiatrists specializing in old age in the Netherlands

BACKGROUND: Current guidelines consider electroconvulsive therapy (ECT) in the Netherlands a treatment of choice for a depressive disorder with psychotic features, severe suicidal behavior, severe physical exhaustion, or resistance to treatment with antidepressants (consecutively SSRIs, TCAs, lithium, MAO inhibitors). It is advised to use ECT early on in the treatment of depressed elderly patients. In practice, ECT is applied to only a minority of depressed elderly patients in the Netherlands. This situation dates back to the 1970s, in which strong aversive opinions toward ECT grew in the Netherlands, largely as a reaction to the malpractice of ECT in that time and influenced by social-cultural opinions toward psychiatry. Negative attitudes among professionals and lack of knowledge may contribute to the under use in depressed elderly patients. METHODS: A postal questionnaire was sent to 152 psychiatrists who specialize in old age to assess their opinions and attitudes toward ECT. RESULTS: Only a small minority thought ECT was a treatment of choice in a depressive disorder with psychotic features (4%), severe suicidal risk (2%), or physical exhaustion (5%). The majority of the psychiatrists had strongly reserved opinions in considering ECT as a treatment of first, second or third choice in depressed elderly patients, even in treatment-resistant depressive disorders. CONCLUSIONS: Many psychiatrists who specialize in old age in the Netherlands divert from the current guidelines and are reluctant toward using ECT as a treatment of choice in a number of specific, clinical situations. This might be a major contributing factor to the present and past underuse of ECT in depressed elderly patients in the Netherlands.     

Knowledge of attitude toward experience and satisfaction with electroconvulsive therapy in a sample of Iranian patients

Despite the wide consensus over the safety and efficacy of electroconvulsive therapy (ECT), it still faces negative publicity and unfavorable attitudes of patients and families. Little is known about how the experience with ECT affects the patients' and their families' attitude toward it. The aim of this study was to examine a sample of Iranian patients and their families regarding their experience with ECT and to compare their knowledge and attitude toward ECT before and after this experience and their satisfaction with it. We surveyed 22 patients with major depressive disorder about to undergo ECT and 1 family member of each patient for their knowledge and attitude toward ECT and then surveyed them again after the trial of ECT to compare those variables while assessing their experience and satisfaction with ECT. Patients were rated using the Hamilton Depression Rating Scale and Mini-Mental Status Examination before and after the treatment. We found that, before ECT, family members had a more favorable attitude toward ECT than patients, but after ECT, the patients' attitude changed more positively compared with their families. Both patients and their families had a poor knowledge of ECT before the ECT trial, but their total knowledge increased afterward, although not in the areas of indications and therapeutic effects. The majority of patients and their families found ECT to be beneficial and were satisfied with it. Satisfaction with ECT was independent of treatment outcome. There was a high rate of perceived coercion to consent to ECT. Attention should be paid toward educating patients and their families about the ECT process, indications, risks, safety, and effects as well as informing them about their freedom of choice and right to refuse.     

A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities

BACKGROUND: Controversy persists about the use of right unilateral (RUL) and bilateral (BL) electroconvulsive therapy (ECT). While RUL ECT results in less severe short-term and long-term cognitive effects, there is concern that it is less efficacious than BL ECT. METHODS: In a double-blind study, 80 depressed patients were randomized to RULECT, with electrical dosages 50%, 150%, or 500% above the seizure threshold, or BL ECT, with an electrical dosage 150% above the threshold. Depression severity and cognitive functioning were assessed before, during, immediately after, and 2 months after ECT. Compared with baseline, responders had at least a 60% reduction in symptom scores 1 week after ECT, and were monitored for relapse for 1 year. RESULTS: High-dosage RUL and BL ECT were equivalent in response rate (65%) and approximately twice as effective as low-dosage (35%) or moderate-dosage (30%) unilateral ECT. During the week after the randomized phase, BL ECT resulted in greater impairment than any dosage of unilateral ECT in several measures of anterograde and retrograde memory. Two months after ECT, retrograde amnestic deficits were greatest among patients treated with BL ECT. Thirty-three (53%) of the 62 patients who responded to ECT relapsed, without treatment group differences. The relapse rate was greater in patients who had not responded to adequate pharmacotherapy prior to ECT and who had more severe depressive symptoms after ECT. CONCLUSION: Right unilateral ECT at high dosage is as effective as a robust form of BL ECT, but produces less severe and persistent cognitive effects.     

ECT response after relapse during continuation repetitive transcranial magnetic stimulation. A case report.

Research on repetitive transcranial magnetic stimulation (rTMS) indicates that the treatment of non-psychotic depression is comparable to electroconvulsive therapy (ECT) in terms of short-term outcome. We report on a woman who exerted a recurrent moderate major depressive episode, 6 months after discontinuation of maintenance ECT. She responded to acute rTMS treatment which was followed by the rTMS maintenance-protocol. Within 2 months of continuation rTMS she relapsed suffering from a severe non psychotic depressive episode and had to be switched to a successful ECT. In this patient rTMS had a good clinical impact as an acute treatment strategy, but failed to prevent relapse as the continuation ECT previously did in the same patient.     

A survey of psychiatrists' attitudes toward electroconvulsive therapy

Sixty-seven psychiatrists who were employed in state hospitals in Texas were surveyed about their attitudes toward use of electroconvulsive therapy (ECT) and the laws and regulations associated with its use. The majority of respondents agreed with accepted professional guidelines on ECT usage and had a positive attitude toward ECT treatment. However, the number of referrals for ECT by these psychiatrists was low, perhaps due to the view that Texas laws and policies about ECT are restrictive and limiting to patient care. The majority of respondents indicated that more professional education about laws and policies related to ECT is needed.     

Cognitive style, cortical function, and electroconvulsive therapy

Performance on the rod and frame test (RFT) was measured over three separate occasions in three groups of 20 depressive patients and a nonpatient control group. Depressive patients were selected into three groups according to whether they had been prescribed one of three forms of treatment: bilateral electroconvulsive therapy (ECT), nondominant unilateral ECT, or a course of antidepressant drugs. The RFT was administered on three occasions: before treatment, 1 week after completion of treatment, and at 3 months follow-up. The control group received no treatment, but were tested at comparable periods. The RFT was scored as mean absolute error and also as separate frame-dependent, rod-dependent, and constant error components. All depressive groups showed improved error measures post-treatment. The two ECT groups showed less frame dependence post-treatment than the drug group. The group receiving bilateral ECT showed a greater decrease in the mean error of performance than the unilateral group. Right-sided unilateral ECT affected frame dependence in patients who were initially frame independent, rather than in those who were initially frame dependent. The results indicated that the effect of ECT may depend on a patient's initial pretreatment cognitive style.     

Effects of an education training program on attitudes to electroconvulsive therapy

Widespread negative attitudes toward electroconvulsive therapy (ECT) are present in the general public and among heath care professionals. However, there is evidence to suggest that clinical experience and knowledge of ECT positively improve attitudes toward this treatment. The purpose of this study was to evaluate the effects of an ECT education training program on attitudes toward ECT. Participants were 73 student nurses (91.8% women) and 21 care aid students (81.0% women) undertaking a 6-week rotation in psychiatry at a large provincial psychiatric hospital in British Columbia, Canada. The ECT education training program consisted of a brief lecture, viewing of an educational videotape, familiarization with the ECT equipment, and observation of an ECT treatment. Participants completed a short questionnaire pretraining and posttraining program. Attitudes toward ECT did not substantially differ between the 2 groups. For the entire sample, only 8.5% reported that they were well informed about ECT before the training session. More favorable attitudes were reported upon completion of the ECT education program compared with attitudes reported before training. These findings suggest that attitudes toward ECT increase favorably when individuals are provided with training and experience.     

Successful maintenance electroconvulsive therapy for more than seven years

We report on a patient with recurrent major depressive episodes with psychotic features who was successfully treated with maintenance electroconvulsive treatment (M-ECT) over a long period without the need for concurrent treatment with an antidepressant or mood stabilizer. She started ECT in 1996 and has received M-ECT for more than 7 years. To date (2005), she has received 244 treatments. After 5 admissions in nearly 4 years, involving 29 months in hospital, she has not needed any further psychiatric admission for 7 1/2 years since the start of the M-ECT. Her depression has been in complete remission for nearly 6 years, with the exception of one mild-to-moderate nonpsychotic depressive episode lasting for 2 months. The patient exhibited slight cognitive deficits but had no subjective complaints before ECT, and her cognitive deficits did not worsen after the initial ECT. Thus M-ECT does not appear to cause cognitive deterioration. M-ECT is being continued on the patient's request.     

Efficacy of continuation ECT and antidepressant drugs compared to long-term antidepressants alone in depressed patients

OBJECTIVE: The purpose of this study was to evaluate the efficacy of continuation ECT in depression. METHOD: The authors used retrospective chart review to identify 29 patients who received continuation ECT plus long-term antidepressant treatment after a positive response to acute treatment with ECT for a depressive episode (continuation ECT group). A retrospective case-controlled approach was used to ascertain a matching group of 29 patients who received long-term antidepressant treatment alone after responding positively to acute ECT (antidepressant-alone group). All 58 patients (46 with unipolar depression, 12 with bipolar disorder) had been chronically depressed before receiving acute ECT. Data from medical records were analyzed by using survival analysis and proportional hazards regression to determine outcome and risk factors. RESULTS: The mean duration of the follow-up period for all patients was 3.9 years (5.4 years for the continuation ECT patients and 2.4 years for the antidepressant-alone patients). Outcome was significantly better in the continuation ECT group. The cumulative probability of surviving without relapse or recurrence at 2 years was 93% for continuation ECT patients and 52% for antidepressant-alone patients. At 5 years, survival declined to 73% for continuation ECT patients, but fell to 18% for antidepressant-alone patients. Mean survival times were 6.9 years for the continuation ECT patients and 2.7 years for the antidepressant-alone patients. CONCLUSIONS: The findings provide strong support for the efficacy of continuation ECT plus long-term antidepressant treatment in preventing relapse and recurrence in chronically depressed patients who have responded to acute treatment with ECT.     

The effectiveness of electroconvulsive therapy in treatment-resistant depression: a naturalistic study

OBJECTIVES: Electroconvulsive therapy (ECT) is a very effective treatment of major depressive disorder. However, its use has been declining over the years in the United Kingdom, where it is now reserved for cases where all other treatment options have failed. We wanted to assess whether ECT is still highly effective in such a severely treatment-resistant population. METHODS: We report results from an ongoing, prospectively conducted, naturalistic study examining the effectiveness of ECT at a general psychiatric hospital in Cardiff, United Kingdom. We present results on every patient who received ECT between March 2004 and August 2006 for major depressive episodes, had a baseline 24-item Hamilton Rating Scale for Depression (HRSD24) score of greater than or equal to 18 and consented for participation. RESULTS: We analyzed the results of 38 patients who had at least 6 ECT sessions or achieved remission earlier. They had spent on average 14.6 months in their current episodes and 6.2 years of their lifetime in depression. They had failed to respond to an average of 5.4 different pharmacological treatments. Twenty-five patients (65.8%) responded (improvement in HDRS24 of >or=50%) and 21 (53.3%) achieved remission (end point HDRS24 score or=60%). There was no correlation between the number of unsuccessful antidepressant trials and improvement (r = -0.04, P = 0.8). CONCLUSIONS: The ECT is still highly effective in severely treatment-resistant patients with major depressive disorder, with more than half of such patients achieving remission.     

Transcranial magnetic stimulation: experience, knowledge and attitudes of recipients

OBJECTIVE: To examine the experience, knowledge and attitudes of recipients of transcranial magnetic stimulation (TMS) regarding the treatment. There have been no studies of patient views about TMS. METHOD: A 60-item survey was administered by telephone to persons with depressive illness who received TMS at Royal Hobart Hospital, Tasmania. RESULTS: Forty-eight patients were interviewed. About two-thirds also had a history of treatment with electroconvulsive therapy (ECT). Experience and opinions about TMS were generally very positive. Almost three-quarters of interviewees believed TMS had been helpful. The vast majority rated TMS as more acceptable than having, or the prospect of having, ECT. The majority would have TMS again and would recommend it to others. CONCLUSIONS: The mostly favourable experiences and attitudes reported by interviewees will be reassuring to patients, their families and treating health professionals when TMS is being considered.     

Improvement in response times for simple and complex tasks after electroconvulsive therapy

BACKGROUND: Electroconvulsive therapy (ECT) has gone through fundamental changes since its introduction in 1938 and has developed from a frightening and distrusted procedure into an effective and safe treatment for people with severe psychiatric disorders. This study suggests that ECT has an effect on the response times of simple and complex tasks. METHODS: We had two groups. The first group consisted of eight patients suffering from severe therapy-resistant depression. They were treated with ECT. The second group consisted of eight sex- and age-matched persons who were treated conventionally with antidepressive medication. The authors measured auditory and visual response times of both simple and complex tasks in run A and run B on two different days. In the ECT group, the first measurement took place 1 day before a session of ECT, the second 3 h following a session of ECT. In the depressive control group, the two measurements were performed on two different days but at most within 4 days. RESULTS: The response times of the depressive subjects treated with ECT are prolonged in both run A and run B compared to those of the depressive control group. The response times in run B are reduced compared to run A on the whole. However the reduction is stronger in the ECT group than the one taking place in the depressive control group between the two runs. CONCLUSIONS: The considerable decrease of the response times from run A to run B in the ECT group compared to the depressive control group gives further evidence that ECT has a positive effect on important information processing parameters.     

Can cognitive behavioral therapy reduce relapse rates of depression after ECT? a preliminary study

OBJECTIVE: The goal of this study was to explore the potential of providing cognitive behavioral therapy (CBT) after an index course of electroconvulsive therapy (ECT) for depression to improve long-term outcome. METHOD: The Beck Depression Inventory (BDI) and Clinical Global Impression (CGI) scale were used to assess depression and treatment outcome for 6 patients who received 12 weeks of CBT after an index course and concurrent with a continuation course of ECT. RESULTS: Patients either maintained their response or showed decreased depressive symptoms at the 6-month post-index ECT evaluation. At the 9-month follow-up, 5 of 6 patients had BDI scores below their post-index ECT scores. The CGIs were rated "much improved" or "very much improved" by 5 patients at the termination of CBT. All 6 patients maintained or improved their CGIs at the 6-month follow-up. CONCLUSIONS: These results provide preliminary evidence that CBT after ECT is feasible and may extend the antidepressant effects ofECT.     

Patients' and their relatives' knowledge of,experience with,attitude toward,and satisfaction with electroconvulsive therapy in Hong Kong,China

Although electroconvulsive therapy (ECT) is a safe and efficacious treatment, there is a widespread negative view of ECT in public and professional circles. There are no data on Chinese patients' knowledge of, experience with, attitude toward, and level of satisfaction with ECT in Hong Kong. The aims of this study were to examine patients' experience of ECT, and patients' and their relatives' knowledge of, attitude toward, and level of satisfaction with ECT. To this effect, a prospective cross-sectional survey was conducted, involving 96 patients and their 87 relatives. The study showed that the majority of patients believed they had not received adequate information about ECT. The most commonly reported side effect was memory impairment. Patients and relatives had only limited knowledge of ECT, yet the majority of them were satisfied with the treatment and, having found it beneficial, maintained a positive attitude toward its use. The researchers concluded that Hong Kong Chinese patients and their relatives accepted ECT as a treatment. The way information is provided to patients and relatives when obtaining consent for ECT needs improvement.     

Patient and Family Perspectives of Electroconvulsive Therapy: Correlation with Outcome

We surveyed 25 patients about to undergo electroconvulsive therapy (ECT) and one relative of each patient for their attitudes, knowledge, and opinions about ECT; and then resurveyed them after the course of ECT. Patients were rated with the Hamilton Depression Rating Scale or Young Mania Rating Scale, based on diagnosis, before and after ECT. Patients and family members had highly positive attitudes toward ECT both before and after treatment, and after the course felt strongly that the ECT was beneficial. Baseline depression severity gave a high correlation with positive post-ECT attitudes.     

Treatment outcome, seizure duration, and the neurophysin response to ECT

Serum concentrations of immunoreactive neurophysin (IRN) and vasopressin-associated neurophysin (hNpI) were measured before and after the first treatment in a course of electroencephalographically monitored electroconvulsive therapy (ECT) given to 19 depressed patients. The difference (DIFF) between the serum concentrations of IRN and hNpI is equivalent to the concentration of oxytocin-associated neurophysin. Before ECT the six patients who had a good outcome at 2 months after the course of ECT had a mean serum IRN concentration one-half (p less than 0.05) and a mean serum DIFF concentration one-third (p less than 0.05) that of the 13 patients who had a poor outcome. The increase in serum DIFF concentration (but not IRN or hNpI) after the first ECT correlated with the improvement on the Hamilton Rating Scale for Depression (r = -0.73, p less than 0.005) and the Montgomery and Asberg Depression Rating Scale (r = -0.49, p less than 0.05). The peak percentage increase in serum DIFF concentrations after ECT was 4 times greater (p less than 0.001) in the good outcome group than in the poor outcome group. None of the neurophysin responses to ECT correlated with electroencephalogram-measured seizure duration.     

Propofol and methohexital as anesthetic agents for electroconvulsive therapy: a randomized, double-blind comparison of electroconvulsive therapy seizure quality, therapeutic efficacy, and cognitive performance

BACKGROUND: Propofol is often used as an anesthetic agent for electroconvulsive therapy (ECT). Whether the relatively short seizure duration, resulting from the medication, deteriorates the seizure quality and therapeutic outcomes, or whether propofol might be associated with small but significant post-ECT cognitive impairments, is still a subject of controversy. The purpose of our study was to test these hypotheses in comparison with methohexital. MATERIALS AND METHODS: In a double-blind, controlled study, 50 patients with severe major depression who were to be treated with ECT were randomly assigned to anesthesia with propofol (120.9 +/- 50.0 mg) or methohexital (83 +/- 26.3 mg) and were observed for 2 months. The 2 drugs were compared on the basis of electroencephalography-registered seizure duration, mean blood pressure, as well as pulse frequency, seizure efficacy index, and postictal suppression. Systolic and diastolic blood pressure, and seizure duration and quality were recorded consecutively during ECT treatments. Changes in depressive symptoms and cognitive functions were measured at 5 time points, pre-ECT, after the third to fifth ECT, post-ECT treatment, and at a follow-up examination 2 and 8 weeks after the last ECT treatment. RESULTS: Patients on propofol showed a significantly lower increase in blood pressure post-ECT (P < 0.001), their seizure duration was comparable to patients on methohexital (P = 0.072), and seizure quality was significantly superior, as was measured by the Postictal Suppression Index (P = 0.020), and comparable to the methohexital group as measured by the Seizure Efficacy Index (P = 0.160). The improvement of depressive symptoms and the improvement in cognitive functions were similar in both groups (with the exception of the results from 2 cognition tests). CONCLUSIONS: Propofol, as compared with methohexital, results in a more moderate increase in blood pressure and shorter seizure duration. The seizure quality did not differ significantly between the 2 groups. We detected a tendency toward improved cognitive performance after anesthesia with propofol as compared with methohexital, but with statistical significance in only 2 cognition trials. Therefore, propofol is a safe and efficacious anesthetic for ECT treatment.     

A preliminary study of the effects of electroconvulsive therapy on regional brain glucose metabolism in patients with major depression

Animal studies have shown that a course of electroconvulsive shock (ECS) leads to a significant reduction in glucose metabolism in rat brains 1 day after the last ECS. In humans, of the two positron emission tomography (PET) studies that assessed the effects of a course of electroconvulsive therapy (ECT) on brain glucose metabolism in depressed patients, one reported no change while the other found a trend for reduction in glucose metabolism in frontal cortical region 24 hours after last ECT. The changes in glucose metabolism detected 24 hours after the last ECS/ECT treatment might simply be due to subacute effects of a seizure. We hypothesized that the changes in brain metabolism that persist 1 week after a course of ECT are more likely to underlie the therapeutic effects of ECT. We, therefore, investigated the effects of a course of ECT on brain glucose metabolism 1 week after last ECT by using PET and [18F]fluorodeoxyglucose (FDG). Six patients who met DSM-IV criteria for a diagnosis of major depressive disorder (unipolar), and were referred for ECT as the clinically indicated treatment were recruited. They underwent two PET scans, one prior to first ECT and the second a week after last ECT. The number of ECT treatments subjects received ranged from 8 to 12 with a mean of 11. Five out of six patients responded to the ECT treatment. Cerebral metabolic rates for glucose were slightly lower in most regions post treatment compared with pretreatment but the differences were not statistically significant. Similarly, there was no significant correlation between changes in regional cerebral metabolic rates for glucose (rCMRglc) and changes in Hamilton Depression Rating Scale (HAM-D 21-item) scores. Our results might suggest that rCMRglc rates are not altered 1 week after a therapeutic course of ECT in depressed patients. Further studies using new generation PET scanners, which have a higher resolution, in larger numbers of depressed patients, are clearly needed before firm conclusions can be drawn.     

A dissociation between anterograde and retrograde amnesia after treatment with electroconvulsive therapy: a naturalistic investigation

OBJECTIVE: The aim of the present study is to investigate the cumulative effects of a clinically determined course of electroconvulsive therapy (ECT) on anterograde and retrograde amnesia. In this study, mood and memory were examined in the context of a protocol driven by therapeutic response, rather than by preordained research criteria. METHODS: Twenty-two patients with major depressive disorder and 18 nondepressed controls were taught a series of faces and names before the initiation of ECT, and their retention of this information was examined after the end of treatment. Anterograde (ie, new learning) and retrograde memory (ie, recall of information learned before ECT) were assessed. Eleven ECT patients underwent unilateral (UL) stimulation, and 11 had a combination of UL and bilateral stimulation. Major depressive disorder patients and nondepressed controls participants were matched according to baseline memory abilities. Unilateral and unilateral/bilateral (UB) ECT patients were matched according to baseline depression and memory abilities. RESULTS: Treatment with ECT resulted in a dissociation between anterograde and retrograde memory; after treatment, major depressive disorder patients demonstrated significant retrograde amnesia, whereas there was no change in their anterograde memory. Unilateral and UB ECT patients performed equally well on tasks of anterograde memory. Contrary to our expectation, UB ECT was not associated with greater retrograde memory loss than was UL ECT treatment. However, a trend toward a group difference was present on 1 memory measure. CONCLUSIONS: Results of the study suggest that a clinical course of ECT is associated with isolated impairment for information learned before treatment (ie, retrograde memory), whereas there was no effect of ECT on posttreatment learning abilities (ie, anterograde memory).     

Attitudes towards electroconvulsive therapy among Hungarian psychiatrists

Participants of a postgraduate biologic psychiatric course were surveyed about their attitudes toward electroconvulsive therapy (ECT) with a self-administered questionnaire. Among the respondents, 65 persons were specialists in psychiatry, 32% of whom would not consider using ECT even if they were in a psychotic depressive state. According to the bias factor, which has been calculated based on the answers to the 11 questions regarding attitudes, those psychiatrists who worked in inpatient care showed a less negative attitude. Among the items concerning knowledge of ECT, incorrect answers were most frequent to questions about myocardial infarction as a contraindication, and about the identity of the person who had pioneered this treatment. The negative attitude of Hungarian psychiatrists, especially of those who work in outpatient care, may have an important role in the decrease of the application of ECT in the past decade in Hungary.