The effect of continuation and maintenance electroconvulsive therapy on cognition: A systematic review of the literature and meta-analysis

Practice of Electroconvulsive Therapy in Catalonia in 2022: Results From a Large Cross-Sectional Survey

INTRODUCTION

The practice of electroconvulsive therapy (ECT) exhibits variability across various domains, both between regions, and between centers within the same region. The ECT Working Group of the Catalan Society of Psychiatry conducted a comprehensive survey in Catalonia, Spain, to assess the current status of those variables essential in the clinical practice of ECT.

MATERIALS AND METHODS

The survey comprised 50 items, including various question types such as multiple-choice, numerical response, and open-ended questions. It was administered to the 20 public hospitals that currently provide ECT in Catalonia during the year 2022. Information was gathered on 4 main areas: Organization of the ECT Unit, Specific Technique of ECT Application, Strategies and Organization of the Therapeutic Plan, and Epidemiological Data, Training, and Healthcare Resource Management.

RESULTS

Some notable findings include an application rate of 1.1 per 10,000 inhabitants, major depression diagnosis as the primary indication for ECT in 80% of the centers, and the ability to perform maintenance ECT in 100% of centers.

CONCLUSIONS

Following the survey and analysis, 3 main findings emerged: minimal variation in ECT application rates compared to the previous decade, increased complexity in current ECT practices with a focus on quality and patient safety, and identified areas for improvement in resource management and the necessity for a well-trained and stable multidisciplinary team.

Study protocol of a German multi-center, observer-blind, randomized, and actively controlled parallel-group trial comparing maintenance electroconvulsive therapy to treatment as usual for relapse prevention in clozapine resistant schizophrenia

BACKGROUND

Schizophrenia is one of the most severe and costly mental disorders in terms of human suffering and societal expenditure. About 15-30% of patients do not respond to all known antipsychotics, including clozapine, the current gold standard in these cases. Electroconvulsive therapy (ECT) is well-known to be highly effective in clozapine-treatment-resistant schizophrenia (CRS), and synergistic effects of clozapine and ECT have been demonstrated. However, relapse rates after successful courses of ECT are still very high, and evidence for maintenance ECT (mECT) in CRS is scarce at best.

METHODS

Here, we present the protocol of the MECT-RESIST trial, a German multi-center, observer-blind, randomized, and actively controlled parallel-group clinical trial. The scientific aim of the study is to test the hypothesis that mECT plus treatment as usual (TAU) (intervention group) is superior to TAU alone (control group) for relapse prevention in CRS. The primary endpoint is time to relapse. Secondary endpoints include the proportion of relapse-free patients, the global level of functioning and quality of life, depressive symptoms, overall symptoms of schizophrenia, concomitant catatonic symptoms, stress and self-stigmatization and cognitive performance. We aim at randomizing 84 patients between 18 and 65 years with a clinically diagnosed CRS and brief psychotic rating scale (BPRS) > 45, who responded to a series of ECT (BPRS < 70% of initial BPRS), to either recieve mECT + TAU or TAU over a period of 28 weeks followed by a follow-up of 12 months. The study will be performed between 2025 and 2028.

DISCUSSION

In this multi-center trial, we aim to examine the effectiveness of mECT in CRS patients who improved after a course of routine ECT. If mECT will lead to a longer time to relapse and/or to a higher proportion of relapse-free patients compared to those undergoing treatment as usual, this trial would have an enormous impact on therapeutic strategies for patients with CRS and would induce a profound change of current treatment guidelines, where ECT still ranks at the level of ultima ratio, despite accumulating evidence suggesting otherwise.

TRIAL REGISTRATION

ClincalTrials.gov NCT06456983, registered 7 Jun 2024. Deutsches Register Klinischer Studien DRKS00036886, registered 14 May 2025.

Evaluation of the Efficacy of Electroconvulsive Therapy in Relation to the Anesthetic Agent Applied: A Retrospective Analysis

OBJECTIVES

The present study aims to make a contribution to the extant literature on the sharing of clinical experiences with electroconvulsive therapy (ECT) and the effects of different anesthetic drugs on ECT efficacy.

METHODS

A retrospective analysis of the medical records of patients who were administered ECT from March 2023 to July 2024 was conducted to obtain data on age, gender, psychiatric diagnosis, type of psychiatric drugs used, the effectiveness of ECT, type of anesthetic agent administered during ECT, and the side effects after ECT.

RESULTS

A total of 149 patients were included in the study, of whom 81 (54.4%) were female and 68 (45.6%) were male, with a mean age of 41.72 years (±15.68). At least 1 side effect related to ECT was reported in 23 patients. When the number of effective sessions was analyzed according to the anesthetic agent used, the number of effective sessions of ECT was statistically significantly higher in patients who received ketamine alone than in patients who received propofol, propofol to ketamine, and propofol ketamine combination (P < 0.001, P < 0.001, P = 0.011, respectively). No significant relationship was found between the type of anesthetic agent and side effects (P = 0.059).

CONCLUSIONS

The combination of ketamine and propofol may be regarded as a safer option in terms of side effects and cognitive functions when compared with their use in isolation. Furthermore, the utilization of ketamine as an anesthetic agent in patients exhibiting ineffective seizures can be regarded as a viable alternative strategy.

Pediatric suicide: Review of a preventable tragedy

Concepts of suicide are explored in this issue with a focus on suicide in children and adolescents. The epidemiology of pediatric suicide in the United States is reviewed; also, risk and protective factors, as well as prevention strategies, are discussed. Suicide in the pediatric athlete and the potential protective effect of exercise are examined. In addition, this analysis addresses the beneficial role of psychological management as well as current research on pharmacologic treatment and brain stimulation procedures as part of comprehensive pediatric suicide prevention. Though death by suicide in pediatric persons has been and remains a tragic phenomenon, there is much that clinicians, other healthcare professionals, and society itself can accomplish in the prevention of pediatric suicide as well as the management of suicidality in our children and adolescents.

The myth of brain damage: no change of neurofilament light chain during transient cognitive side-effects of ECT

Electroconvulsive therapy (ECT) is an effective, safe, and mostly well-tolerated treatment for patients with severe or difficult to treat depression or psychotic disorders. However, a relevant number of patients experience subjective and/or objective cognitive side-effects. The mechanism of these transient deficits is not yet clear. Thus, our study prospectively investigated neurofilament light chain (NfL) concentrations as a highly sensitive biomarker for neuroaxonal damage along with cognitive performance during a course of ECT. Serum NfL concentrations from 15 patients with major depressive disorder receiving ECT were analyzed (1) 24 h before the first ECT, (2) 24 h and (3) 7 days after the last ECT (45 measurements in total). Neuropsychological testing including memory, executive functions and attention was performed at each time-point. NfL concentrations did not change between the three time-points, while a temporary cognitive impairment was found. Even in the subset of patients with the strongest impairment, NfL concentrations remained unchanged. Neuropsychological testing revealed the common pattern of transient cognitive side-effects with reduced performance 24 h post-ECT (global cognition score: p < 0.001; memory: p = 0.043; executive functions: p = 0.002) and return to baseline after 7 days (all p < 0.001). Our study adds to the evidence that neither ECT per se nor the transient cognitive side-effects seem to be associated with an increase of NfL as a marker of neuroaxonal damage. In contrast, we discuss cognitive side effects to be potentially interpreted as a byproduct of ECT's neuroplastic effects.

Effects of Aphrodite (an Herbal Compound) on SSRI-Induced Sexual Dysfunctions and Depression in Females with Major Depressive Disorder: Findings from a Randomized Clinical Trial

Background and Objectives: Almost by default, people with major depression disorder (MDD) also report sexual health issues. This holds even more true when sexual dysfunctions are SSRI-induced. Herbal compounds may have the power to counterbalance such sexual dysfunctions, though research is still scarce. Therefore, we assessed females with diagnosed MDD treated with a standard SSRI (sertraline) and reporting SSRI-induced sexual dysfunctions, and we asked whether compared to placebo, Aphrodite (a blend of ginger, saffron, cinnamon, thistle, and Tribulus terrestris) may favorably impact on sexual dysfunctions, and on symptoms of depression, anxiety, and sleep disturbances. Materials and Methods: A total of 41 females (mean age: 35.05 years) with diagnosed MDD, treated with sertraline (a standard SSRI) at therapeutic dosages, and reporting SSRI-induced sexual dysfunction, were randomly assigned either to Aphrodite or to the placebo condition. At baseline and four and eight weeks later (study end), participants completed a series of self-rating questionnaires covering symptoms of sexual dysfunction, depression, anxiety, and sleep complaints. Results: Symptoms of sexual dysfunction, depression, and anxiety decreased over time, but more so in the Aphrodite condition, compared to the placebo condition (significant p-values and large effect sizes). Over time, sleep disturbances decreased irrespective of the study condition. Conclusions: The pattern of results suggests that compared to placebo, Aphrodite appeared to improve symptoms of sexual dysfunction, depression, and anxiety among females with diagnosed MDD and SSRI-induced sexual dysfunction. Further and similar studies should investigate the underlying psychophysiological mechanisms.

Effect of Continuation-Maintenance Electroconvulsive Therapy on Hospitalization: A Retrospective Mirror-Image Study

Objective

To examine the effect of continuation-maintenance electroconvulsive therapy (ECT) on psychiatric hospitalization in Thai patients.

Methods

This retrospective mirror-image study reviewed medical records of Thai patients who received continuation-maintenance ECT at Ramathibodi Hospital, Bangkok, between September 2013 and December 2022. The initiation of continuation-maintenance ECT served as the index event, establishing pre-initiation and post-initiation periods. The primary outcome measured the differences in admissions and admission days before and after continuation-maintenance ECT.

Results

Forty-seven patients were included in the study, with diagnoses of schizophrenia (38.3%), schizoaffective disorder (21.3%), and bipolar disorder (19.1%) being the most common. The mean (standard deviation; SD) age was 44.6 (12.2) years. The total duration that patients received continuation-maintenance ECT was 53 ± 38.2 months. Following the initiation of ECT, there was a significant reduction in the median (interquartile range) number of hospitalizations for all patients (2 [2] versus 1 [2], p < 0.001), as well as for the psychotic disorder group (2 [2] versus 1 [2.75], p = 0.006) and the mood disorder group (2 [2] versus 1 [2], p = 0.02). Moreover, there was a significant reduction in the median (interquartile range) length of admission days for all patients after the initiation of continuation-maintenance ECT (66 [69] versus 20 [53], p < 0.001). Specifically, the psychotic disorder group (64.5 [74] versus 15.5 [62], p = 0.02) and mood disorder group (74 [57] versus 20 [54], p = 0.008) demonstrated statistically significant decreases in admission days.

Conclusion

Continuation-maintenance ECT may be an effective treatment option for reducing hospitalizations and admission days in patients with various psychiatric diagnoses. However, the study also highlights the need to carefully consider the potential adverse effects of ECT in clinical decision-making.

Non-Invasive Neuromodulation Methods to Alleviate Symptoms of Huntington's Disease: A Systematic Review of the Literature

Huntington's disease (HD) is a progressive and debilitating neurodegenerative disease. There is growing evidence for non-invasive neuromodulation tools as therapeutic strategies in neurodegenerative diseases. This systematic review aims to investigate the effectiveness of noninvasive neuromodulation in HD-associated motor, cognitive, and behavioral symptoms. A comprehensive literature search was conducted in Ovid MEDLINE, Cochrane Central Register of Clinical Trials, Embase, and PsycINFO from inception to 13 July 2021. Case reports, case series, and clinical trials were included while screening/diagnostic tests involving non-invasive neuromodulation, review papers, experimental studies on animal models, other systematic reviews, and meta-analyses were excluded. We have identified 19 studies in the literature investigating the use of ECT, TMS, and tDCS in the treatment of HD. Quality assessments were performed using Joanna Briggs Institute's (JBI's) critical appraisal tools. Eighteen studies showed improvement of HD symptoms, but the results were very heterogeneous considering different intervention techniques and protocols, and domains of symptoms. The most noticeable improvement involved depression and psychosis after ECT protocols. The impact on cognitive and motor symptoms is more controversial. Further investigations are required to determine the therapeutic role of distinct neuromodulation techniques for HD-related symptoms.