Electroconvulsive therapy and age: Age-related clinical features and effectiveness in treatment resistant major depressive episode

Understanding the Patient Landscape: A Ten-Year Retrospective Examination of Electroconvulsive Therapy in Romania's Largest Psychiatric Hospital

The aim of this analysis was to investigate the socio-demographic and clinical profile, the effectiveness, and the association of pharmacological treatment in patients who underwent electroconvulsive therapy during the last 10 years in the largest psychiatric hospital in Romania. This study includes 249 patients aged between 18 and 73 years old. Recurrent depression was the most frequent diagnosis for which ECT was performed (T = 96, 38.55%), followed by schizophrenia (T = 72, 28.91%). The most frequent indication for ECT was treatment resistance (T = 154, 61.84%), followed by persistent suicidal ideation (T = 54, 21.68%) and catatonia (T = 42, 16.86%). In 111 (44.60%) cases included in this study, re-hospitalization was required after performing ECT, while 138 (55.40%) participants did not require any further hospital readmissions. Significant differences were found between these groups in terms of socio-demographic data, diagnosis, number of ECT sessions performed, and association of psychotropic medication during and after the procedure, therefore two separate patient profiles were found based on these characteristics. Patients necessitating re-hospitalization post-ECT were mainly males aged 25-44 diagnosed with schizophrenia and underwent a greater number of ECT sessions (7-12), whereas those not requiring re-hospitalization were predominantly females aged 45-64 with recurrent depressive disorder for which 4-6 ECT sessions were performed.

Response to electroconvulsive therapy in elderly patients with late-onset bipolar disorder: The impact of cerebral small vessel disease

OBJECTIVES

Cerebral Small Vessel Disease (CSVD) is a chronic, progressive vascular disorder that confers increased vulnerability to psychiatric syndromes, including late-life mood disorders. In this study, we investigated the impact of CSVD on electroconvulsive therapy (ECT) outcomes in patients with late-onset bipolar disorder (BD).

METHODS

A sample of 54 non-demented elderly patients (≥60 years) with late-onset BD and treatment-resistant major depression, mixed state, or catatonia who underwent bilateral ECT were included in this naturalistic observational study. A diagnosis of CSVD was established based on brain neuroimaging performed before ECT. All patients were evaluated before and after ECT using the Brief Psychiatric Rating Scale (BPRS), the Hamilton Rating Scale for Depression (HAM-D), and the Clinical Global Impression scale (CGI).

RESULTS

Of the total sample, 19 patients were diagnosed with CSVD (35.2%). No significant differences were observed at baseline between patients with and without CSVD. Overall, a response was obtained in 66%-68.5% of patients, with remission in 56.2%. No significant differences in ECT outcomes were found between those with and without CSVD, and both groups exhibited substantial improvements in symptom severity following ECT.

CONCLUSIONS

The outcome of ECT in late-onset BD was not influenced by the presence of CSVD. This finding aligns with previous research on unipolar depression. Accordingly, ECT should be considered for elderly patients with late-onset BD, regardless of the presence of CSVD.

Electroconvulsive therapy-induced volumetric brain changes converge on a common causal circuit in depression

Neurostimulation is a mainstream treatment option for major depression. Neuromodulation techniques apply repetitive magnetic or electrical stimulation to some neural target but significantly differ in their invasiveness, spatial selectivity, mechanism of action, and efficacy. Despite these differences, recent analyses of transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS)-treated individuals converged on a common neural network that might have a causal role in treatment response. We set out to investigate if the neuronal underpinnings of electroconvulsive therapy (ECT) are similarly associated with this causal depression network (CDN). Our aim here is to provide a comprehensive analysis in three cohorts of patients segregated by electrode placement (N = 246 with right unilateral, 79 with bitemporal, and 61 with mixed) who underwent ECT. We conducted a data-driven, unsupervised multivariate neuroimaging analysis Principal Component Analysis (PCA) of the cortical and subcortical volume changes and electric field (EF) distribution to explore changes within the CDN associated with antidepressant outcomes. Despite the different treatment modalities (ECT vs TMS and DBS) and methodological approaches (structural vs functional networks), we found a highly similar pattern of change within the CDN in the three cohorts of patients (spatial similarity across 85 regions: r = 0.65, 0.58, 0.40, df = 83). Most importantly, the expression of this pattern correlated with clinical outcomes (t = -2.35, p = 0.019). This evidence further supports that treatment interventions converge on a CDN in depression. Optimizing modulation of this network could serve to improve the outcome of neurostimulation in depression.

Outcomes of electroconvulsive therapy in patients with depressive symptoms with versus without comorbid personality disorders/traits: A systematic review and meta-analysis

AIMS

To assess electroconvulsive therapy (ECT) outcomes in patients affected by depressive symptoms with versus without additional comorbid personality disorders/traits.

METHODS

We identified observational studies investigating ECT clinical outcomes in patients affected by depressive symptoms with versus without comorbid personality disorders/traits in Embase/Medline in 11/2022. Our protocol was registered with PROSPERO (CRD42023390833). Study quality was evaluated using the Newcastle-Ottawa-Scale. Our primary outcomes were ECT response and remission rates. Meta-regression analyses included effects of in/outpatient percentages, age, number of ECT sessions, and electrode placement; subgroup analyses included the assessment methods for personality disorders/traits. We performed sensitivity analyses after excluding poor-quality studies.

RESULTS

A total of 20 studies (n = 11,390) were included in our analysis. Patients with comorbid personality disorders/traits had lower remission rates (OR = 0.42, 95% CI = 0.31, 0.58, p < 0.001) with substantial heterogeneity (I2  = 93.0%) as well as lower response rates (OR = 0.35, 95% CI = 0.24, 0.51, n = 5129, p < 0.001) with substantial heterogeneity (I2  = 93.0%) compared with patients without comorbid personality disorders/traits. Relapse rates were higher in patients with versus without comorbid personality disorders/traits (OR = 3.23, 95% CI = 1.40, 7.45, k = 4, n = 239, p = 0.006) with moderate heterogeneity (I2  = 75.0%) and post-ECT memory impairment was more frequent in patients with versus without comorbid personality disorders/traits (OR = 1.41, 95% CI = 1.36, 1.46, k = 4, n = 471, p < 0.001) with minimal heterogeneity (I2  = 0.0%). Dropout rates were higher in patients with versus without comorbid personality disorders/traits (OR = 1.58, 95% CI = 1.13, 2.21, k = 3, n = 6145, p = 0.008).

CONCLUSIONS

Patients with comorbid personality disorders/traits treated with ECT are reported to have lower response and remission rates and higher rates of side effects and relapse rates compared with patients without personality disorders/traits.

Response rate and safety of antidepressants combined with electroconvulsive therapy in adolescent depression: Real-world clinical application

BACKGROUND

METHODS: This study included 210 depression patients receiving antidepressants and ECT. The symptoms of depression were examined with the Hamilton Depression Scale (HAMD) and Clinical Global Impressions Scale (CGI) at baseline and the end of treatment. Response and safety were compared among adolescent and adult patients.

RESULTS

For adolescents, the response rate (much improved or very much improved) was 80.9 %, and CGI-Severity (CGI-S), HAMD, and suicide factor scores were significantly changed as compared to baseline (P < 0.001), results of which were similar to the adult group. There were no significant differences in HAMD, CGI scores between adolescent and adult depression before or after treatment (P > 0.05). Notably, adolescents expressed stronger suicidal intent than adults, and ECT observably relieved it. Side effects (memory problems, headache, nausea/vomiting, muscle soreness) in adolescents were not statistically different from those in adults (P > 0.05).

LIMITATIONS

As data were derived from a single center, the generalizability of results may be limited, and the potential factors affecting the efficacy of ECT were not further explored.

CONCLUSION

Antidepressants combined with ECT are associated with high response rate and safety for treating depression, regardless of age. A stronger expression of suicide ideation was observed in depressed adolescents, and side effects of ECT were similar to the adults.

A Review of Therapeutics for Treatment-Resistant Depression in the Older Adult

One-third of older adults with depression meet criteria for treatment resistance, typically defined as a lack of response to two or more adequate trials of an antidepressant. Treatment resistance contributes to an unfavorable prognosis, compromised medical outcomes, heightened disability, accelerated cognitive decline, and an elevated risk of developing dementia. Despite this significant morbidity, evidence is sparse for how to proceed with treatment in this population. Non-pharmacologic therapy (e.g., diet, psychotherapy) can be utilized as adjunctive therapy, despite little published evidence of benefit, given that the risks are low. Pharmacotherapy trials in the treatment-resistant late-life depression population lack strong methods and external validity; however, the use of venlafaxine as monotherapy and add-on therapy, as well as lithium, bupropion, or aripiprazole as add-on therapy to standard antidepressant therapy, have enough evidence that a trial with appropriate monitoring is a prudent strategy. Electroconvulsive therapy remains a well-studied safe therapy, especially when used as maintenance treatment once an initial cycle is completed but is traditionally underutilized in the treatment-resistant late-life depression population. Ensuring non-pharmacologic and pharmacologic strategies are optimized and given a sufficient trial in those with treatment-resistant late-life depression is the best we can do for this vulnerable population.

Effects of electroconvulsive therapy on cerebral A1 adenosine receptor availability: a PET study in patients suffering from treatment-resistant major depressive disorder

Introduction

Sleep deprivation and electroconvulsive therapy (ECT) effectively ameliorate symptoms in major depressive disorder (MDD). In rodents, both are associated with an enhancement of cerebral adenosine levels, which in turn likely influence adenosinergic receptor expression. The aim of the current study was to investigate cerebral A1 adenosine receptor (A1AR) availability in patients with MDD as a potential mediating factor of antidepressant effects of ECT using [18F]CPFPX and positron emission tomography (PET).

Methods

Regional A1AR availability was determined before and after a series of ECT applications (mean number ± SD 10.4 ± 1.2) in 14 subjects (4 males, mean age 49.5 ± 11.8 years). Clinical outcome, measured by neuropsychological testing, and ECT parameters were correlated with changes in A1AR availability.

Results

ECT had a strong antidepressive effect (p < 0.01) while on average cerebral A1AR availability remained unaltered between pre-and post-ECT conditions (F = 0.65, p = 0.42, mean difference ± SD 3.93% ± 22.7%). There was no correlation between changes in clinical outcome parameters and regional A1AR availability, although individual patients showed striking bidirectional alterations of up to 30-40% in A1AR availability after ECT. Solely, for the mean seizure quality index of the applied ECTs a significant association with changes in A1AR availability was found (rs = -0.6, p = 0.02).

Discussion

In the present study, therapeutically effective ECT treatment did not result in coherent changes of A1AR availability after a series of ECT treatments. These findings do not exclude a potential role for cerebral A1ARs in ECT, but shift attention to rather short-termed and adaptive mechanisms during ECT-related convulsive effects.

Treatment-resistant depression in children and adolescents

Major depressive disorder (MDD) in children and adolescents is a significant health problem, causing profound impairments in social, academic, and family functioning and substantial morbidity and mortality. Up to 15% of children and adolescents suffer from MDD, and a proportion, around 30 to 40% of them, failed to respond to initial selective serotonin reuptake inhibitor (SSRI) treatment. The only evidence-based recommendation is medication switching to another SSRI and augmentation with cognitive behavioral therapy. Newly developing treatment, including ketamine, transcranial magnetic stimulation, psychotherapy other than cognitive behavioral therapy, and combined pharmacotherapy with other interventions, requires further longitudinal controlled trials regarding efficacy and safety in this vulnerable population.

Electroconvulsive therapy-induced volumetric brain changes converge on a common causal circuit in depression

Neurostimulation is a mainstream treatment option for major depression. Neuromodulation techniques apply repetitive magnetic or electrical stimulation to some neural target but significantly differ in their invasiveness, spatial selectivity, mechanism of action, and efficacy. Despite these differences, recent analyses of transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS)-treated individuals converged on a common neural network that might have a causal role in treatment response. We set out to investigate if the neuronal underpinnings of electroconvulsive therapy (ECT) are similarly associated with this common causal network (CCN). Our aim here is to provide a comprehensive analysis in three cohorts of patients segregated by electrode placement (N = 246 with right unilateral, 79 with bitemporal, and 61 with mixed) who underwent ECT. We conducted a data-driven, unsupervised multivariate neuroimaging analysis (Principal Component Analysis, PCA) of the cortical and subcortical volume changes and electric field (EF) distribution to explore changes within the CCN associated with antidepressant outcomes. Despite the different treatment modalities (ECT vs TMS and DBS) and methodological approaches (structural vs functional networks), we found a highly similar pattern of change within the CCN in the three cohorts of patients (spatial similarity across 85 regions: r = 0.65, 0.58, 0.40, df = 83). Most importantly, the expression of this pattern correlated with clinical outcomes. This evidence further supports that treatment interventions converge on a CCN in depression. Optimizing modulation of this network could serve to improve the outcome of neurostimulation in depression.

Predictors of cognitive changes in patients with schizophrenia undergoing electroconvulsive therapy

INTRODUCTION

Previous studies on the effects of electroconvulsive therapy (ECT) on cognition in schizophrenia have been inconclusive. This study aimed to identify factors that may predict cognitive improvement or deterioration in patients with schizophrenia after-ECT.

MATERIALS & METHODS

Patients with schizophrenia or schizoaffective disorder with predominantly positive psychotic symptoms, who were treated with ECT at the Institute of Mental Health (IMH), Singapore, between January 2016 and January 2018, were assessed. Montreal Cognitive Assessment (MoCA), Brief Psychiatric Rating Scale (BPRS) and Global Assessment of Function (GAF) were performed before and after ECT. Patients with clinically significant improvement, deterioration or no change in MoCA scores were compared on demographics, concurrent clinical treatment and ECT parameters.

RESULTS

Of the 125 patients analysed, 57 (45.6%), 36 (28.8%) and 32 (25.6%) showed improvements, deterioration and no change in cognition respectively. Age and voluntary admission predicted MoCA deterioration. Lower pre-ECT MoCA and female sex predicted MoCA improvement. Patients showed improvements in GAF, BPRS and BPRS subscale scores on average, except for the MoCA deterioration group, who did not show statistically significant improvement in negative symptom scores. Sensitivity analysis showed that nearly half the patients (48.3%) who were initially unable to complete MoCA pre-ECT were able to complete MoCA post-ECT.

CONCLUSIONS

The majority of patients with schizophrenia demonstrate improved cognition with ECT. Patients with poor cognition pre-ECT are more likely to see improvement post-ECT. Advanced age may be a risk factor for cognitive deterioration. Finally, improvements in cognition may be associated with improvements in negative symptoms.

The Use of ECT in the Elderly-Looking Beyond Depression

PURPOSE OF REVIEW

We reviewed recent evidence on the use of electroconvulsive therapy (ECT) in the geriatric population. This review looked at the literature on depression, for which there is a breadth of data, as well as other conditions that have historically not been as well studied, as well as attempting to provide practical recommendations for ECT practitioners. This review also examined the impact of the COVID-19 pandemic on ECT in the elderly.

RECENT FINDINGS

ECT shows robust efficacy across many psychiatric diseases, from depression and bipolar disorder to psychosis and catatonia. It has also shown positive results at improving behavioral symptoms of dementia, as well as improving motor symptoms seen in Parkinson's disease. It is routinely found to be a safe treatment as well, generally with only minimal transient side effects. ECT should not be considered a "last-resort" treatment for geriatric patients suffering from psychiatric disorders. It has historical and recent literature supporting its use in many psychiatric disorders and has been shown to be safe with minimal side effects when appropriate considerations are taken for the elderly population.

First Acute-Course Electroconvulsive Therapy for Moderate-to-Severe Depression Benefits Patients With or Without Accompanying Baseline Cognitive Impairment

BACKGROUND

Researchers are increasingly investigating therapeutic response associated with new patient subgroups as a way to improve electroconvulsive therapy (ECT) treatment outcomes and reduce adverse events. This study is the first to examine baseline cognitive impairment status as a predictor of clinical outcome in first acute-course ECT patients.

METHODS

Baseline cognitive function at various thresholds and serial depressive symptom severity data from first-time ECT patients were examined using generalized linear mixed-effects models.

RESULTS

Of 1345 patients who met the inclusion criteria, 617 had available data at their third assessment visit (~15th treatment visit). There was a robust improvement in depression symptoms over time (P < 0.0001), and cognitive function was not associated with baseline levels of depressive symptoms or serially measured change in self-reported symptom severity during acute-phase ECT.

CONCLUSIONS

These results indicate that an acute course of ECT for the treatment of moderate-to-severe depression benefits patients with or without accompanying baseline cognitive impairment. These findings may be useful in informing shared decision-making discussions about ECT risks and expected benefits.

Focal points of preanesthesia evaluations for electroconvulsive therapy in patients with depression: a retrospective analysis of clinical characteristics in nonremission

Background

This study explored the patient clinical characteristics that may affect electroconvulsive therapy (ECT) efficacy to enable improved focus during evaluations and preparation for ECT.

Methods

Patients were enrolled for ECT at the Department of Psychiatry and Anesthesiology of the First Affiliated Hospital of Chongqing Medical University from December 2017 to January 2019. The primary outcome in our study was defined as the development of nonremission. A multivariate logistic analysis was performed to identify the risk factors for nonremission.

Results

In total, 874 depressed patients were included in the study. After the ECT treatment, 255 cases (29.2%) exhibited nonremission. A multivariate logistic regression analysis of the variables was performed, and the results showed that atherosclerosis (OR 8.072, 95% CI 2.442 to 16.675; P = 0.001), COPD (OR 2.919, 95% CI 1.240 to 6.871; P = 0.014), diabetes (OR 2.202, 95% CI 1.115 to 4.348; P = 0.023) and smoking (OR 1.519, 95% CI 1.015 to 2.273; P = 0.042) were independent risk factors for nonremission.

Conclusion

In the retrospective analysis, we found that atherosclerosis, diabetes, COPD and smoking may be high-risk factors for nonremission.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01686-6.

Real-world evidence of age-independent electroconvulsive therapy efficacy: A retrospective cohort study

OBJECTIVES

Electroconvulsive therapy (ECT) is an effective treatment for depressive disorders and approved for use in adolescents and adults, but it is unclear whether efficacy or cognitive side effect burden differs with age or if effectiveness in usual clinical practice matches that in prospective studies. We examined the effects of ECT on depression and cognition in a large clinical cohort.

METHODS

A retrospective cohort study of patients ages 16 and older receiving ECT between 2011 and 2020 and who were evaluated with the Quick Inventory of Depressive Symptomatology (QIDS), the Behavior and Symptom Identification Scale-24 (BASIS-24), and the Montreal Cognitive Assessment (MoCA) at baseline and after treatment #10.

RESULTS

Among 1698 patients, ECT was associated with a decrease in depression symptoms (QIDS reduction from 17.1 ± 4.9 to 10.1 ± 5.2) and improvement in self-reported mental health (BASIS-24 scores improved from 1.92 ± 0.55 to 1.17 ± 0.60). There was a reduction in MoCA scores from 25.8 ± 3.1 to 25.4 ± 3.1. In multivariate models, age was not associated with a differential QIDS or BASIS-24 response, but older age was associated with a lesser reduction in MoCA.

CONCLUSION

Among 1698 patients aged 16 and older, ECT was associated with improvement in depression and overall self-reported mental health, with a slight decrease in cognition. Age was not associated with changes in efficacy, but older age was associated with a lesser cognitive change as measured by the MoCA. These results provide normative data of real-world effectiveness of ECT, and add further support to its utility in patients with severe psychiatric illness.

Longitudinal Neurocognitive Effects of Combined Electroconvulsive Therapy (ECT) and Pharmacotherapy in Major Depressive Disorder in Older Adults: Phase 2 of the PRIDE Study

OBJECTIVE

There is limited information regarding neurocognitive outcomes of right unilateral ultrabrief pulse width electroconvulsive therapy (RUL-UB ECT) combined with pharmacotherapy in older adults with major depressive disorder. We report longitudinal neurocognitive outcomes from Phase 2 of the Prolonging Remission in Depressed Elderly (PRIDE) study.

METHOD

After achieving remission with RUL-UB ECT and venlafaxine, older adults (≥60 years old) were randomized to receive symptom-titrated, algorithm-based longitudinal ECT (STABLE) plus pharmacotherapy (venlafaxine and lithium) or pharmacotherapy-only. A comprehensive neuropsychological battery was administered at baseline and throughout the 6-month treatment period. Statistical significance was defined as a p-value of less than 0.05 (two-sided test).

RESULTS

With the exception of processing speed, there was statistically significant improvement across most neurocognitive measures from baseline to 6-month follow-up. There were no significant differences between the two treatment groups at 6 months on measures of psychomotor processing speed, autobiographical memory consistency, short-term and long-term verbal memory, phonemic fluency, inhibition, and complex visual scanning and cognitive flexibility.

CONCLUSION

To our knowledge, this is the first report of neurocognitive outcomes over a 6-month period of an acute course of RUL-UB ECT followed by one of 2 strategies to prolong remission in older adults with major depression. Neurocognitive outcome did not differ between STABLE plus pharmacotherapy versus pharmacotherapy alone over the 6-month continuation treatment phase. These findings support the safety of RUL-UB ECT in combination with pharmacotherapy in the prolonging of remission in late-life depression.

Transient Cognitive Impairment and White Matter Hyperintensities in Severely Depressed Older Patients Treated With Electroconvulsive Therapy

BACKGROUND

Although electroconvulsive therapy (ECT) is a safe and effective treatment for patients with severe late life depression (LLD), transient cognitive impairment can be a reason to discontinue the treatment. The aim of the current study was to evaluate the association between structural brain characteristics and general cognitive function during and after ECT.

METHODS

A total of 80 patients with LLD from the prospective naturalistic follow-up Mood Disorders in Elderly treated with Electroconvulsive Therapy study were examined. Magnetic resonance imaging scans were acquired before ECT. Overall brain morphology (white and grey matter) was evaluated using visual rating scales. Cognitive functioning before, during, and after ECT was measured using the Mini Mental State Examination (MMSE). A linear mixed-model analysis was performed to analyze the association between structural brain alterations and cognitive functioning over time.

RESULTS

Patients with moderate to severe white matter hyperintensities (WMH) showed significantly lower MMSE scores than patients without severe WMH (F(1,75.54) = 5.42, p = 0.02) before, during, and post-ECT, however their trajectory of cognitive functioning was similar as no time × WMH interaction effect was observed (F(4,65.85) = 1.9, p = 0.25). Transient cognitive impairment was not associated with medial temporal or global cortical atrophy (MTA, GCA).

CONCLUSION

All patients showed a significant drop in cognitive functioning during ECT, which however recovered above baseline levels post-ECT and remained stable until at least 6 months post-ECT, independently of severity of WMH, GCA, or MTA. Therefore, clinicians should not be reluctant to start or continue ECT in patients with severe structural brain alterations.

Efficacy of electroconvulsive therapy as a potential first-choice treatment in treatment-resistant depression (Review)

Electroconvulsive therapy (ECT) is a technique that has been used since 1938 to treat several psychiatric disorders as a replacement for chemically induced seizures. Despite its history of stigma, controversy and low accessibility, ECT is found to be beneficial and efficient in severe cases of depression where medication fails to bring results. Titration tables developed over time, based on evidenced-based medicine, have made this treatment technique safe and, in some cases, the first choice of treatment. The aim of the review was to summarize the research conducted on the efficacy of ECT on major depressive disorder and variables studied such as technique, comorbidities and medication as well as the effects and outcomes of this procedure. At the same time, the application and correlations with other psychiatric and neurological disorders, including catatonia, agitation and aggression in individuals with dementia, schizophrenia, and epilepsy were assessed. There are no statistically demonstrated effects due to the fact that a small number of moderate-quality studies have been published; however, the combination of ECT technique with standard medication and care, can improve patient outcome. Furthermore, with regard to ECT, widespread and robust volume changes in both cortical and subcortical regions have been shown. Antidepressant response and volumetric increases appear to be limited by the specific neuroplasticity threshold of each patient.

The Efficacy and Cognitive Effects of Acute Course Electroconvulsive Therapy Are Equal in Adolescents, Transitional Age Youth, and Young Adults

Objective: Electroconvulsive therapy (ECT) is the most effective acute treatment for depression, but its use in younger patients is rare and heavily regulated in many U.S. states. It is unclear whether age modifies treatment response or tolerability in adolescents, transitional age youth, and young adults. We examined the effects of ECT on depression and cognition in patients aged 16-30 years. Methods: A retrospective cohort study of patients aged 16-30 years receiving ECT between 2011 and 2020 who were evaluated with the Quick Inventory of Depressive Symptomatology (QIDS), the Behavior and Symptom Identification Scale-24 (BASIS-24), and the Montreal Cognitive Assessment (MoCA) at baseline and following treatment #10. Results: Among the 424 patients who met the inclusion criteria, ECT was associated with a decrease in depression symptoms (ΔQIDS -6.7; Kruskal-Wallis rank sum test; χ² = 293.37; df = 2; p < 0.0001) and improvement in overall self-reported mental health status (ΔBASIS-24 - 0.70; Kruskal-Wallis rank sum test; χ² = 258.5; df = 2; p < 0.0001) during the first 10 treatments, with a slight reduction in cognition as measured by the MoCA (ΔMoCA -1.1; Kruskal-Wallis rank sum test; χ² = 33.7; df = 1; p < 0.0001). Age was not a significant predictor of QIDS, BASIS-24, or MoCA changes. Conclusions: Among 424 patients aged 16-30 years receiving acute course ECT, age was not a significant predictor of improvement in depression, change in overall self-reported mental health status, or change in cognition. These results support the utility of ECT in the treatment of adolescents and young adults.

Electroconvulsive Therapy in Children and Adolescents: A Systematic Review of Current Literature and Guidelines

ABSTRACT

There is a lack of studies regarding the efficacy of electroconvulsive therapy (ECT) in children and adolescents. In this study, we aimed to assess benefits and harms of ECT in children and adolescents with major psychiatric diseases. We conducted a systematic search in PubMed, EMBASE, and PsycINFO for peer-reviewed articles written in English regarding the use of ECT as treatment for major psychiatric diseases in children and adolescents. This study consists of 192 articles, mostly case studies (n = 50), reviews and overview articles (n = 52), and retrospective studies (n = 30). We present an overview of evidence for ECT in children and adolescents with mood disorders, catatonia, schizophrenia, intellectual disability, self-injurious behavior, and other indications. This article is also a summary of international guidelines regarding the use of ECT in children and adolescents. We evaluated the overall quality of evidence by using Grading of Recommendations, Assessment, Development and Evaluations and found the overall level of evidence to be of low quality. There are no absolute contra indications for ECT in children and adolescents. Fears regarding cognitive dysfunction have not been reproduced in studies. Electroconvulsive therapy should be considered in severe, treatment-resistant mood disorders, catatonia, and schizophrenia, especially in older adolescents. High-quality studies are warranted to assess the efficacy of ECT, especially in these potentially life-threatening diseases.

Geriatric Depression and Cognitive Impairment-An Update

BACKGROUND

Depression and cognitive impairment often coexist in older adults. The relation between depression and cognitive impairment is complex. The objective of this article is to review recent literature on cognitive impairment in older adults with depression and provide clinicians an update.

METHODS

We searched PubMed, Google Scholar, Science Direct, and Psych Info for the articles published in the English language related to late-life depression (LLD)/geriatric depression and cognitive impairment. We considered original research articles, relevant systematic reviews, chapters, and important conceptual articles published in the last 9 years (2011-2019). We selected relevant articles for this narrative review.

CONCLUSION

The concept pseudodementia, indicating depression with cognitive impairment mimicking dementia, is now seen only as a historical concept. The current literature strongly agrees with fact that cognitive deficits often exist in LLD. The cognitive deficits in depression were initially seen as trait marker; however, some recent studies suggest that cognitive deficits persist even in the remission phase. There is heterogeneity among the studies in terms of the nature of the cognitive deficits, but higher number of studies reported impairment in attention and executive function. LLD with cognitive deficits is at a higher risk of progression to dementia. In older adults, depression with cognitive impairments requires a comprehensive evaluation. Electroencephalography, event-related potentials, fluorodeoxyglucose-positron emission tomography, amyloid positron emission tomography, and CSF amyloid will supplement clinical evaluation in differentiating functional depressive disorder with cognitive impairment from depression with an underlying degenerative condition.

Electroconvulsive Therapy and Age: Effectiveness, Safety and Tolerability in the Treatment of Major Depression among Patients under and over 65 Years of Age

Electroconvulsive therapy (ECT) remains the most effective therapy in treatment-resistant depression. However, the safety of ECT has been consistently questioned, particularly among elderly patients. We assessed the efficacy and safety of ECT in patients before and after 65 years old. The study was conducted between 2015 and 2018 and included 91 patients (61 under and 29 over 65 years old) with major depression undergoing ECT. The Hamilton Depression Rating Scale was used to evaluate efficacy. Cognitive functions were assessed using: MMSE, RAVLT, Trail Making Test, Stroop Test and Autobiographical Memory Interview-Short Form. ECT was more effective in older patients as compared to younger (p < 0.001). No serious adverse events were observed in either group. Increased blood pressure and arrhythmias were more common in the older compared to the younger group (p = 0.044 and p = 0.047, respectively), while disturbances of consciousness did not differ between groups (p = 0.820). Most of the cognitive functions remained unchanged compared to baseline, whereas the outcomes of MMSE, RAVLT and Stroop tests showed greater improvements in the older compared to the younger group (all p < 0.05). The decline in the retrieval consistency of autobiographical memory was more pronounced in the younger group (p = 0.024). ECT is a highly effective, safe and well-tolerated method of treating depression regardless of age.

Right unilateral versus bilateral formula-based electroconvulsive therapy in the treatment of major depression in elderly patients: a randomised, open label, pilot controlled trial

BACKGROUND

Electroconvulsive therapy (ECT) remains the most effective treatment of depression in the elderly population; however, it is still unclear which type of ECT is most beneficial in this population. The aims of this study were: (i) to assess the feasibility of a randomised controlled trial in elderly depressed patients treated with right unilateral (RUL) or fronto-temporal bilateral (BT) formula-based ECT; (ii) to compare formula-based RUL and BT ECT in terms of efficacy, safety and tolerability in this population.

METHODS

The study lasted 3 years and managed to randomise 29 patients over 65 years old to receive either BT (n = 14) or RUL (n = 15) ECT. Brief pulse width (0.5 ms) and age-based dosing method were applied. The clinical efficacy was assessed using Hamilton Depression Rating Scale, somatic state was monitored throughout the ECT course. In neuropsychological examination general cognitive performance, executive functions, verbal fluency, memory, autobiographical memory were evaluated.

RESULTS

The recruitment was poor due to small number of patients able to give informed consent. ECT proved to be a highly effective and safe method of treatment among elders. Formula-based RUL ECT did not differ from BT in antidepressant efficacy and had cognitive advantages - the indices of general cognitive performance, verbal fluency and memory were significantly better than before the treatment in the RUL group. Decline in retrieval consistency of autobiographical memory was more pronounced in the BT group, although it was observed across both groups.

CONCLUSIONS

Formula-based RUL ECT might not differ from BT in antidepressant efficacy and has an advantage in terms of tolerability.

Impact of vascular risk factors on clinical outcome in elderly patients with depression receiving electroconvulsive therapy

BACKGROUND

Although electroconvulsive therapy (ECT) is a highly effective, safe, and well-tolerated antidepressant treatment for late-life depression (LLD), there is large variability in response rates across individuals. We hypothesized that these variations would be in part explained by the level of vascular risk in this population. We therefore compared response rates to ECT in patients with LLD presenting with or without vascular risk factors (VRF).

METHODS

52 patients with LLD (age > 55) who received a course of ECT were separated into 2 groups according to the presence of VRF (n = 20) or not (n = 32). Framingham score (10-year risk for developing a coronary heart disease) was calculated for each patient. Our primary outcome was the number of responders to ECT in each group (defined as at least 50% decrease of the Montgomery-Åsberg Depression Rating Scale score following ECT course). Scores at the self-rated Beck Depression Inventory are also reported.

RESULTS

Patients with VRF presented significant lower response rates to ECT (12 out of 20; 60%) than patients without VRF (30 out of 32; 94%; p = 0.004). A negative correlation was found between Framingham score and changes in depression scores pre/post ECT (r = -0.42; p = 0.0039).

LIMITATIONS

Our study was limited by sample size and retrospective design.

CONCLUSION

Patients with LLD and VRF showed lower response rates to ECT than those without VRF. The more the VRF increased, the less the antidepressant effect of ECT was observed. Results are discussed in light of the role of apathy in clinical response to ECT.

Efficacy, safety and tolerability of formula-based unilateral vs bilateral electroconvulsive therapy in the treatment of major depression: A randomized open label controlled trial

Electroconvulsive therapy (ECT) remains the most effective treatment of depression, though it is still unclear which of its type is the most beneficial. The aim of this study was to compare the formula-based right unilateral ECT (RUL) with the fronto-temporal bilateral ECT (BT), in terms of their efficacy, safety and tolerability in patients with bipolar or unipolar depression. Ninety-one patients were randomly assigned to either BT (n = 45) or RUL (n = 46) ECT. Brief pulse width (0.5 ms) and a formula-based dosing method were applied. The clinical efficacy was assessed using the Hamilton Depression Rating Scale (HDRS-21).The somatic state was monitored throughout the ECT course and cognitive examination included: general cognitive performance, executive functions, visual-spatial functions, verbal fluency, verbal memory and autobiographical memory. Efficacy outcomes were not found to be significantly different between groups when using higher doses of energy in RUL ECT. Patients in RUL group were less likely to be confused and experienced increased blood pressure. The indices of general cognitive performance and verbal auditory memory were also significantly better this group, while BT ECT did not change these functions. Both ECT types resulted in a decline in the retrieval consistency of autobiographical memory that persists for at least three months and was significantly more marked in BT group as compared to RUL. In conclusion, formula-based RUL ECT does not differ from BT in antidepressant efficacy and has an advantage in terms of safety (lower incidence of increased blood pressure and fewer disturbances of consciousness) and tolerability (impact on cognitive functions).

Demographics of Patients Receiving Electroconvulsive Therapy Based on State-Mandated Reporting Data

OBJECTIVES

Electroconvulsive therapy (ECT) is an effective treatment of depression and other psychiatric conditions. There are few comprehensive data on how many patients receive ECT in the United States or about the demographics of ECT recipients. This study characterizes the demographics of those receiving ECT and how these demographics may have changed with time.

METHODS

Freedom of information requests for all data from record keeping inception to January 2019 were sent to the Department of Health or equivalent agency of states that mandate reporting of ECT. Information on demographics and the number of treating facilities was extracted.

RESULTS

Data on 62,602 patients receiving treatment in 3 states (California, Illinois, Vermont) were obtained. Overall, 62.3% were women. Fewer than 1% of patients treated were younger than 18 years, whereas 30.3% were 65 years or older. White patients received a disproportionate proportion of treatments, with all other races underrepresented. The total number of facilities offering ECT in the 3 states declined over the study period.

CONCLUSIONS

Recipients of ECT are more likely to be female, more likely to be elderly, and more likely to be white than the average person in their state.

Effects of Electroconvulsive Therapy on Depression and Its Potential Mechanism

Depression is one of the most common disorders causing mortality around the world. Although electroconvulsive therapy (ECT) is, along with antidepressants and psychotherapy, one of the three major treatments of depression, it is still considered as the last resort for depressed patients. This situation is partially due to limited studies and uncertainty regarding its mechanism. However, decades of increased research have focused on the effects of ECT on depression and its potential mechanism. Furthermore, these investigations may suggest that ECT should be a first-line therapy for depression due to its profound effects in relieving desperation in certain situations. Here, we outline recent clinical and preclinical studies and summarize the advantages and disadvantages of ECT. Thus, this review may provide some hints for clinical application.

Acute Phase Treatment Outcomes of Electroconvulsive Therapy in Adolescents and Young Adults

OBJECTIVE

Electroconvulsive therapy (ECT) is a highly efficacious, well-tolerated treatment in adults. Little is known, however, about its effectiveness in adolescents and young adults. Our objectives were to assess clinical outcomes after acute phase ECT in adolescents and young adults and determine whether screening positive or negative for a substance use disorder (SUD) is associated with differences in treatment outcomes.

METHODS

Study sample consisted of all patients 16 to 25 years old who received ECT from May 2011 to August 2016 and who completed self-reported SUD screens and the Behavior and Symptom Identification Scale-24 (BASIS-24) initially and completed the BASIS-24 again after the fifth ECT treatment. For 5 BASIS-24 domains, longitudinal changes in mean domain scores were assessed; mean changes by SUD screening status were also examined using linear mixed models.

RESULTS

One hundred ninety adolescents and young adults, with mean age 21.0 ± 2.6 years, met inclusion criteria. Electroconvulsive therapy was associated with significant clinical improvement (score decreases) in all 5 BASIS-24 domains during the acute phase treatment (P < 0.001). Sixty-four percent (122/190) screened positive for SUD. Compared with adolescents and young adults screening negative for SUD, those screening positive for co-occurring SUD had greater improvement in depression/functioning (-0.37 ± 0.14, P = 0.009), interpersonal relationships (-0.27 ± 0.13, P = 0.045), and emotional lability (-0.27 ± 0.14, P = 0.044) domains after the fifth ECT treatment.

CONCLUSIONS

Electroconvulsive therapy in adolescents and young adults was associated with significantly improved clinical outcomes during acute phase treatment. Adolescents and young adults screening positive for SUD had better acute phase ECT outcomes in self-reported depression/functioning, interpersonal relationships, and emotional lability than those screening negative. More research is needed to clarify adolescents and young adult patient characteristics that may be associated with differential ECT outcomes.