Vasopressin release during electroconvulsive therapy

The therapeutic effect of electroconvulsive therapy (ECT) has been attributed to changes in hypothalamic peptides with behavioural effects. Vasopressin (AVP) has been shown to possess such qualities. We have studied the effect of ECT on AVP release in nine endogenously depressed patients during ECT sessions numbers 1, 2, 5 and 8. Plasma AVP concentration showed a five-fold increase two min after the electric stimulus and fell to nearly basal levels within 10 min. The maximum plasma AVP concentration following ECT was independent of the age of the patients, their basal plasma AVP level, the electric energy of the stimulus, the duration of the seizures and the electrode placement. No changes were found in plasma osmolality, plasma sodium concentration and plasma renin activity. These results indicate that ECT has a transient effect on plasma AVP. Changes in AVP activity within the central nervous system might be a link in the chain of events which form the basis of the therapeutic effect of ECT.     

Asystole during electroconvulsive therapy: a case report.

OBJECTIVE: The objective of the report is to describe a case of asystole lasting for 18 s, which developed after a subconvulsive stimulus during electroconvulsive therapy (ECT) in a patient without pre-existing cardiovascular abnormality. A brief review of the relevant literature is also provided. CLINICAL PICTURE: The patient was a 65-year-old Chinese man with a 2-year history of depression and good past medical health. Earlier he had responded well to a course of ECT without adverse effects. This time he presented with low mood, anhedonia, poor appetite and constipation. He did not respond to adequate trials with several antidepressant medications. When a subconvulsive stimulus was administered to determine the seizure threshold, no seizure activity was detected. However, immediately after the stimulus the patient developed an 18-s asystole, followed by bradycardia of 40 beats per minute for 10 s. The bradycardia resolved spontaneously before therapeutic intervention was effected. TREATMENT: Intravenous atropine was employed as premedication and suprathreshold stimulus was used in further ECT sessions. OUTCOME: Asystole did not recur in the subsequent six ECT sessions. CONCLUSION: When proper precautions are taken, asystole does not necessitate the suspension of further ECT sessions but intravenous atropine should be considered as premedication in such cases. Inducing anaesthesia with methohexital, avoiding excessive amounts of succinylcholine and employing suprathreshold stimulus and unilateral electrode placement may further lessen the likelihood of asystole in susceptible cases.     

Venlafaxin-associated post-ictal asystole during electroconvulsive therapy

While post-stimulus asystoles occur quite often during electroconvulsive therapy (ECT) post-ictal or post-seizure sinus bradycardias or even asystoles are rare events. We report the case of an 82-year-old female patient with a current major depressive episode, who developed the rare event of a post-ictal asystole of 6 s and 4 ventricular escape beats during ECT. In the past this patient with a bipolar disorder and mild Alzheimer's disease had already been frequently treated with ECT with good success and no adverse events. Relevant comedication was venlafaxin, quetiapine, donepezil and clonidine, anesthesia was performed with ketamine and succinylcholine. Concurrent medication was completely unchanged compared to previous ECT sessions with the exception of venlafaxine, presumably at high serum levels. In summary, in line with some already existing reports, we expect the noradrenergic action of venlafaxin to have contributed substantially to the post-ictal asystole and want to indicate that the combination of ECT and venlafaxin might be harmful--especially in the elderly population.     

Maintenance electroconvulsive therapy.

Maintenance electroconvulsive therapy remains an infrequently used and insufficiently researched treatment for the prevention of relapse and recurrence of affective illnesses. The foundation for this treatment is examined by reviewing the relevant scientific literature, with particular attention to identifying those patients who may benefit most from this form of therapy, as well as establishing standard techniques of application. A critical assessment of current research is made, and areas for future investigation are proposed.     

A progress in electroconvulsive therapy: the non-barbiturate anesthaetic drug etomidate.

Forty-six female patients (19-72 years) requiring ECT for psychiatric indications received 0.5 mg atropine, followed by 0.1-0.4 mg/kg bodyweight of etomidate. Subsequently 50 mg of suxamethonium were injected and ECT was applied. The etomidate-ECT combination proved very suitable and was well tolerated.     

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.     

Etomidate and unpredicted seizures during electroconvulsive therapy

Electroconvulsive therapy has been a novel treatment for about half a century, effective for severe psychiatric conditions. Over the years, the treatment has been refined with the addition of anesthesia. Different inducing agents have been used in clinical practice over the last few decades including propofol, methohexital, and etomidate. Previous literature rarely mentions seizures soon after induction with etomidate and typically only in anesthesia literature. We describe 2 cases with different demographics, diagnosis, and treatment that had seizures with the use of etomidate as an inducing agent.     

Awareness under anesthesia during electroconvulsive therapy treatment

ABSTRACT: Awareness under general anesthesia is an infrequent phenomenon during which patients become cognizant of some or all events during surgery or any procedure conducted under anesthesia. Awareness experiences can frighten patients and impact their memories in ways that can leave emotional and psychological problems that, over time, may develop into posttraumatic stress disorder. Inadequate anesthesia has been implicated in the causation of awareness under anesthesia. We report first case of patient gaining awareness while under anesthesia undergoing electroconvulsive therapy treatment. The case reported here would suggest that clinicians administering electroconvulsive therapy should be alert to the possibility of awareness during anesthesia and take appropriate measures to maintain professional conduct and adjust anesthetic medication dose to avoid reoccurrence.     

Change in seizure threshold during electroconvulsive therapy

The seizure threshold (ST) is a measure of the minimum electrical energy necessary to induce a grand mal seizure. Dose titration of the ST has been suggested to optimize stimulus dosing in electroconvulsive therapy (ECT). The change in ST with remission is examined in a large sample of unipolar depressed patients. METHODS: In a study of continuation treatments after successful ECT, the ST was determined at the first treatment and again 1 week after remission using a conventional ST measurement protocol. Patients were treated with bilateral electrode placement at 150% above the measured ST. RESULTS: In 80 subjects, the ST measured the same in 70%, increased in 21%, and decreased in 9% at remission. CONCLUSIONS: In a study of bilateral ECT, the ST did not rise conclusively with remission.     

Patients who develop epilepsy during extended treatment with electroconvulsive therapy.

Epidemiologic data indicate that electroconvulsive therapy (ECT) does not precipitate epilepsy. However, when an ECT patient develops this condition, one is faced with the question as to whether ECT caused it and whether ECT can be safely continued. We describe four patients, two of whom developed definite epilepsy and two possible epilepsy during extended courses of ECT. In one of the patients ECT was stopped at that point, but in the other three, ECT was continued without complications or apparent precipitation of spontaneous seizures. We describe some of the clinical challenges in this scenario and provide recommendations regarding continued use of ECT in the newly diagnosed epileptic patient.     

Intraictal cessation of electroencephalographic activity during electroconvulsive therapy

There have been a few reports of intraictal cessation of electroencephalographic (EEG) activity during electroconvulsive therapy. We present a case of a gentleman with recurrent severe major depressive disorder, who had a "start-stop-start" phenomenon of EEG activity during his electroconvulsive therapy treatment. This brief intraictal arrest of activity demonstrates the importance of continued EEG monitoring to confirm the postictal termination phase.     

Multiple episodes of intraictal cessation during electroconvulsive therapy

A recent case reported an episode of a "stop-start-stop" phenomenon during an electroconvulsive therapy treatment. We report an example of multiple stop-start-stop episodes during several electroconvulsive therapy treatments of a 16-year-old boy.     

Transient improvement of essential tremor during electroconvulsive therapy

We present a patient who demonstrated transient yet significant improvement of essential tremor (ET) during electroconvulsive therapy. To our knowledge, this is the first such report. The improvement lasted during the course of electroconvulsive therapy and was of a similar magnitude to that which she had experienced on a first-line medication for ET. We discuss the potential pathophysiological implications of this observation in light of recent histopathologic findings in patients with ET.