Potentiation of Seizure Length and Clinical Response to Electroconvulsive Therapy by Caffeine Pretreatment: A Case Report

A patient with a history of nonresponse to electroconvulsive therapy (ECT) was treated with ECT modified by i.v. caffeine before electrical stimulation for some of the seizures. Seizures preceded by i.v. caffeine were longer, and led to marked clinical improvement. Caffeine pretreatment may be a method to enhance seizure length and efficacy in resistant patients.     

Atropine and Cognitive Performance After Electroconvulsive Therapy

Two groups of patients receiving bilateral, moderately suprathreshold electroconvulsive therapy (ECT) were compared in their cognitive functions after receiving either 0.5 mg atropine i.v. or no atropine before ECT. The patients were tested for cognitive functions after four treatments using various measures, including orientation; retrograde (verbal and visuospatial) memory for information acquired about 15 minutes pretreatment and tested for about 1 hour posttreatment; anterograde (verbal and visuospatial) memory for information acquired about 1 hour, 30 minutes posttreatment and tested for both immediately after learning and 20 minutes later; and retrieval from semantic memory as assessed by word fluency. We found no effect of 0.5 mg atropine on cognitive performance, even though anticholinergic drugs that cross the blood brain barrier might be expected to affect cognition after ECT.     

Outpatient Electroconvulsive Therapy: Efficacy and Safety

Thirty-two outpatients with a mean age of 68 years were observed in a naturalistic study of outpatient electroconvulsive therapy (ECT) for the management of recurrent mood disorder. Sixty-nine percent of the patients responded favorably to ECT and were either discharged well from therapy or continue in treatment. A rehospitalization rate of 9% supports the efficacy of this treatment. We find outpatient ECT safe for the long-term management of recurrent depressive illness in elderly patients. The low dropout rate demonstrates that patient acceptance is equal to that of other outpatient treatments.     

The Effects of Baseline Impaired Global Cognitive Function on the Efficacy and Cognitive Effects of Electroconvulsive Therapy in Geriatric Patients: A Retrospective Cohort Study

ObjectivesThis study explores the association between baseline impaired global cognitive function and changes in global cognitive function and depression among geriatric patients undergoing acute course electroconvulsive therapy (ECT).DesignRetrospective cohort study.SettingSingle freestanding psychiatric hospital.ParticipantsPatients aged 50 and older receiving ECT.Interventions10 ECT treatments.MeasurementsCognitive assessments with the Montreal Cognitive Assessment (MoCA). Depression assessment with the Quick Inventory of Depressive Symptomatology Self Report 16 item scale (QIDS).ResultsBaseline and follow-up data were available for 684 patients. On average, patients with baseline normal cognition (MoCA ≥26; N = 371) had a decrease in MoCA of -1.44±0.26 points over the course of treatment, while those with baseline impaired global cognitive function (MoCA <26; N = 313) had an increase in MoCA of 1.72±0.25 points. Baseline cognitive status was not associated with a differential response on the QIDS.ConclusionsPatients with baseline impaired global cognitive function did not demonstrate a worsening in cognition following ECT, and baseline global cognitive function was not associated with a differential change in depression with ECT. These results suggest that impaired global cognitive function should not be viewed as a contraindication to ECT in geriatric patients.     

Cognitive Side-effects of Electroconvulsive Therapy in Elderly Depressed Patients

Knowledge about cognitive side-effects induced by electroconvulsive therapy (ECT) in depressed elderly patients is sparse. In this study we investigated changes in the cognitive functioning of non-demented elderly depressed patients receiving ECT (n = 62) compared with healthy elderly people (n = 17). Neuropsychological tests were administered at the start of treatment and again within 1 week after treatment. We computed reliable change indices (RCIs) using simple regression methods. RCIs are statistical methods for analyzing change in individuals that have not yet been used in studies of the acute cognitive side-effects of ECT. At the group level, only letter fluency performance was found to be significantly reduced in the ECT group compared with the controls, whereas both groups demonstrated stable or improved performance on all other measures. At the individual level, however, 11% of patients showed retrograde amnesia for public facts post-ECT and 40% of the patients showed a significant decline in neuropsychological functioning. Decline on a measure of delayed verbal anterograde memory was most common. Our findings indicate that there are mild neurocognitive impairments in the acute phase for a substantial minority of elderly patients receiving ECT. Analysis of reliable change facilitated the illumination of cognitive side-effects in our sample.     

Electroconvulsive Therapy Pulse Amplitude and Clinical Outcomes

IntroductionElectroconvulsive therapy (ECT) pulse amplitude, which determines the induced electric field magnitude in the brain, is currently set at 800–900 milliamperes (mA) on modern ECT devices without any clinical or scientific rationale. The present study assessed differences in depression and cognitive outcomes for three different pulse amplitudes during an acute ECT series. We hypothesized that the lower amplitudes would maintain the antidepressant efficacy of the standard treatment and reduce the risk of neurocognitive impairment.MethodsThis double-blind investigation randomized subjects to three treatment arms: 600, 700, and 800 mA (active comparator). Clinical, cognitive, and imaging assessments were conducted pre-, mid- and post-ECT. Subjects had a diagnosis of major depressive disorder, age range between 50 and 80 years, and met clinical indication for ECT.ResultsThe 700 and 800 mA arms had improvement in depression outcomes relative to the 600 mA arm. The amplitude groups showed no differences in the primary cognitive outcome variable, the Hopkins Verbal Learning Test-Revised (HVLT-R) retention raw score. However, secondary cognitive outcomes such as the Delis Kaplan Executive Function System Letter and Category Fluency measures demonstrated cognitive impairment in the 800 mA arm.DiscussionThe results demonstrated a dissociation of depression (higher amplitudes better) and cognitive (lower amplitudes better) related outcomes. Future work is warranted to elucidate the relationship between amplitude, electric field, neuroplasticity, and clinical outcomes.     

Maintenance Electroconvulsive Therapy in Clinical Practice

Five cases of maintenance electroconvulsive therapy (ECT) are reviewed to illustrate the indications for this treatment. The patients' conditions described are consistent with the recommendations of the 1990 American Psychiatric Association Task Force on ECT. Guidelines and examples for selecting patients for maintenance ECT are presented, but when to preferentially treat with continuation pharmacotherapy versus ECT requires further study. Optimal dosing, interval between treatments, and duration of treatment remain questions. The logistics of the treatment are briefly presented and should be easily incorporated into most ECT programs.     

Relative Efficacy of Unilateral and Bilateral Electroconvulsive Therapy in Melancholia

We compared the efficacy of unilateral nondominant (n = 15) and bilateral (n = 31) electroconvulsive therapy (ECT) in melancholia in 46 consecutive, nonrandomly assigned medication-free patients with endogenous depression. Seizure duration was recorded and, if a seizure lasted <25 s, the stimulus was immediately readministered. There were more missed or brief seizures that required restimulation with unilateral ECT than with bilateral ECT. After five treatments, blind assessments on the Hamilton Rating Scale for Depression showed a 57% improvement in the bilateral group as compared with a 19% improvement in the unilateral group. The unilateral group received more total treatments (mean = 9.9) than did the bilateral group (mean = 7.7). At the conclusion of all ECT treatments, 72% of patients receiving bilateral ECT were substantially improved and 14% partially improved, compared with 32% of patients receiving unilateral ECT with substantial improvement and 30% partial improvement. This difference between the two groups, however, had disappeared by the time of discharge. Although unilateral ECT may induce fewer side effects, we find bilateral treatments to be more efficacious, at least on a short-term basis.     

A Prospective Follow-Up Study of Cognitive Functions After Electroconvulsive Therapy

The authors studied primarily nonmemory cognitive functioning in a sample of 13 melancholic patients tested prior to electroconvulsive therapy (ECT) and at various intervals during a 1-2 year post-ECT follow-up period. Compared with 13 age-matched normal controls, the patients performed significantly worse at baseline and immediately after the sixth ECT, but were not significantly different at the 30-day, 6-month, and 1-2 year assessments. At 1-2 years post-ECT, cognitive impairment among patients was substantially and significantly less than observed pre-ECT.     

Age-Dependent Effects of Electroconvulsive Therapy on Memory

We examined the relation between age and recovery of memory functions after electroconvulsive therapy (ECT). In a group of patients 20-65 years of age, older depressed patients treated with ECT experienced more severe and longer lasting memory deficits than did younger patients. Testing conducted 24-72 h after a course of ECT showed more severe deficits in older patients for verbal and visuospatial anterograde memory, and for retrograde memory. The difference between younger and older subjects was marginal at 1 month follow-up, seen only in differences in verbal anterograde memory. At 6 months follow-up, no difference in memory test scores between older and younger patients was observed. Older patients are more vulnerable to cognitive effects of ECT, and these effects last longer.     

Benzodiazepines and Electroconvulsive Therapy

Benzodiazepines (BZD) possess anticonvulsant properties that may potentially elevate seizure threshold, inhibit seizure propagation, and alter some of the neurobehavioral effects of electroconvulsive shock (ECS) in animal models. Nevertheless, considerable controversy exists regarding the clinical impact of oral BZD use during electroconvulsive therapy (ECT). The existing literature is contradictory, and all studies attempting to address this topic suffer from important design flaws. Most studies are retrospective and some address only seizure duration. Also, studies examining treatment outcome are difficult to compare because of differing types and dosages of BZD, varied electrode placement and stimulus energy, and lack of information about the relationship of the stimulus energy to the patients' seizure thresholds. While firm conclusions must await further studies, limited data suggest that BZD have the potential to shorten seizure duration and decrease treatment efficacy, particularly with unilateral ECT.     

Electroconvulsive Therapy and Prolactin Release: Effects of Stimulus Parameters

We report a study of electroconvulsive therapy (ECT) induced prolactin release in nine patients as a function of treatment electrode placement, stimulus energy, and seizure length. Only electrode placement differentially affected prolactin release, with bilateral ECT yielding larger increments over baseline than unilateral ECT.     

Potential Mechanisms Underlying the Therapeutic Effects of Electroconvulsive Therapy

In spite of the extensive application of electroconvulsive therapy(ECT), how it works remains unclear.So far, researchers have made great efforts in figuring out the mechanisms underlying the effect of ECT treatment via determining the levels of neurotransmitters and cytokines and using genetic and epigenetic tools, as well as structural and functional neuroimaging. To help address this question and provide implications for future research, relevant clinical trials and animal experiments are reviewed.     

Electroconvulsive Therapy and Asymptomatic Meningioma

An elderly depressed female patient, who tolerated antidepressant drugs poorly, was found to have a small and asymptomatic meningioma before she was given electroconvulsive therapy (ECT). She received seven bilateral ECTs without neurological deterioration and had a good clinical result.     

Malignant Hyperthermia and Electroconvulsive Therapy

A 30-year-old man with a personal and family history of malignant hyperthermia and a 7-year history of psychiatric illness unresponsive to various psychotropic medications benefitted from electroconvulsive therapy given in combination with clozapine. Volatile inhalation anesthetics and a depolarizing muscle relaxant (succinylcholine) were assiduously avoided. Dantrolene was administered intravenously before the first treatment but was not used for the remainder of the treatments. Anesthesia was induced with methohexital and atracurium. The treatment course was uneventful.     

Combined Clozapine and Electroconvulsive Therapy

We reviewed consecutive patients (n = 12) at McLean Hospital from 1990 through 1991 treated with the combination of the atypical antipsychotic agent clozapine and electroconvulsive therapy (ECT). There were no adverse effects. Three patients had a marked clinical improvement, one a moderate response, four a minimal response, two minimal to no response, and two no response. Using daily doses of up to 550 mg clozapine, this combination appears to be safe, and may be useful in some patients with treatment-refractory psychosis.