A systematic review of modified electroconvulsive therapy (ECT) to treat delirium

Esketamine alleviates cognitive impairment signs induced by modified electroconvulsive therapy in a depression rat model via the KLF4/p38 MAPK pathway

BACKGROUND

Depression is a common and serious psychiatric disorder with significant impacts on individuals. Modified electroconvulsive therapy (MECT) is an established treatment for severe and treatment-resistant depression, but its cognitive side effects, particularly memory impairments, limit its use. Esketamine (ESK), an FDA-approved antidepressant, has shown neuroprotective effects. However, its role in mitigating MECT-induced cognitive deficits remains unexplored. This study investigates whether ESK could alleviate MECT-induced signs of cognitive impairments in a rat model of depression and explores the underlying mechanisms.

METHODS

Male Sprague-Dawley rats were exposed to chronic unpredictable mild stress (CUMS) model to induce depressive-like behaviors. Rats were then subjected to MECT, ESK treatment, or both. Depression-like behaviors and cognitive functions were evaluated using various tests. Molecular and cellular assays were performed to assess hippocampal neuronal apoptosis, inflammation, and synaptic plasticity, with a focus on the Krüppel-like factor 4 (KLF4) and p38 MAPK signaling pathways.

RESULTS

MECT treatment significantly alleviated depressive-like symptoms but exacerbated cognitive impairments, hippocampal neuronal apoptosis, and neuroinflammation. ESK co-treatment improved depressive behaviors while reversing MECT-induced cognitive deficits, reducing hippocampal apoptosis, and decreasing inflammatory cytokine levels. Furthermore, ESK enhanced synaptic plasticity and upregulated KLF4 expression, which in turn inhibited the activation of the p38 MAPK pathway. Functionally, knockdown of KLF4 diminished the neuroprotective effects of ESK, confirming its critical role in mediating cognitive protection.

CONCLUSIONS

Esketamine mitigates METC-induced cognitive impairment in the animal model, by upregulating KLF4, which inhibits the p38 MAPK pathway, offering a potential therapeutic strategy for improving cognitive outcomes in patients undergoing ECT.

Dexmedetomidine for modified electroconvulsive therapy: a dose-optimized treatment study

OBJECTIVES

To determine the optimal dexmedetomidine dose for hemodynamic stability and recovery quality in modified electroconvulsive therapy (MECT).

METHODS

In this randomized trial, 252 patients receiving MECT were allocated to six groups (placebo, D1-D5; 42/group). Groups D1-D5 received dexmedetomidine (0.2-1.0 μg/kg) 10 min pre-anesthesia, while controls received saline. Hemodynamic parameters heart rate (HR), mean arterial pressure (MAP), seizure duration, propofol requirements, recovery times, and adverse events were analyzed.

RESULTS

Doses ≥ 0.4 μg/kg (D2-D5) significantly reduced HR and MAP versus control (P < 0.05), with prolonged recovery in D4-D5 (P < 0.05). Seizure duration remained unchanged across groups. Propofol use decreased dose-dependently (D2-D5, P < 0.05). The D2 group (0.4 μg/kg) achieved optimal hemodynamic stability without excessive recovery delays.

CONCLUSIONS

Dexmedetomidine pretreatment at 0.4 μg/kg optimizes MECT anesthesia by balancing hemodynamic control, reduced propofol use, and rapid recovery, establishing it as the recommended dose.

Safety of electroconvulsive therapy in the context of physiological and medical complexity: A state-of-the art review

Medical contraindications and complications pose challenges for electroconvulsive therapy (ECT). Most published reports are scattered across various physiological systems and individual disease conditions. This review aimed to evaluate the literature on physiological and medical complexities during ECT and discuss risk mitigation strategies in a comprehensive review. We searched PubMed and Embase for contraindications and precautions during ECT with relevant MeSH terms and appraised previous reviews on the same topic. The results suggest that mortality directly attributed to ECT is extremely rare. Instances of fatalities, including fetal deaths, have been reported after ECT in the presence of recent myocardial infarction, deep vein thrombosis, intracranial aneurysm and tumors, pheochromocytoma, sepsis, and pregnancy. However, there are no definite conclusions or consensus on attributions of the outcomes to ECT in all cases because of the time lag between the treatment and deaths and confounding factors. The risks can be mitigated with safety protocols, adequate stakeholder communication, collaboration with anesthetists and specialists, consultation-liaison services, and ECT education. Overall, ECT remains a relatively safe treatment even in the presence of medical and physiological complexities. In rare instances, certain medical conditions may indicate a high risk for ECT, where practitioners avoid the treatment or administer it with precautions if the risk-benefit ratio favors its use.

Electroconvulsive therapy use in New South Wales between 1944 and 1949

AIMS

To identify clinical and other factors associated with the use of electroconvulsive therapy (ECT) in New South Wales for the period 1944-1949 and to compare with contemporaneous practice.

METHOD

Annual reports of the Inspector-General of Mental Hospitals in NSW (1944/45 to 1948/49) were examined.

MAIN FINDINGS

Seven hospitals reported a total of 8964 courses of treatment during the period. Demographically, 60.6% of patients who received ECT were female, and rural hospitals reported 13.6% of courses. ECT was as likely to be given for non-affective psychoses (37.7%), as for affective psychoses (35.0%). ECT was also administered for confusional states and non-psychotic disorders. Better outcomes were observed for depression, anxiety and confusional states than non-affective psychoses. Recovery rates declined over the study period. Mortality was <1%.

CONCLUSIONS

The clinical indications for ECT in the mid-twentieth century in NSW were much broader than currently. There has been no change in the sex ratio of patients administered ECT or reported mortality.

Methods for maintaining the effects of electroconvulsive therapy in depression treatment in various parts of the world

Introduction: Electroconvulsive therapy (ECT) is one of the most effective treatments in psychiatry. The aim of this study is to present innovative methods for preventing the recurrence of depression after ECT treatment using continuation ECT (c-ECT), maintenance ECT (m-ECT), and pharmacotherapy, as well as to compare different approaches to the use of these methods across different parts of the world. Materials and methods: A review of the available literature was performed by searching the PubMed and Google Scholar databases using the following keywords: “c-ECT”, “m-ECT”, “continuation electroconvulsive therapy”/”kontynuacja terapii elektrowstrząsowej”, “maintenance electroconvulsive therapy”/”podtrzymująca terapia elektrowstrząsowa”, “major depressive disorder”/”duże zaburzenia depresyjne”, “continuation pharmacotherapy”/”kontynuacja farmakoterapii” for original papers, meta-analyses, and review papers both in Polish and English, published from 1999 to 2023. The SANRA scale was used to maintain the quality of the narrative review. Results: In maintenance treatment, c-ECT and m-ECT achieve effects comparable to those of pharmacological treatment. The most effective method is a combination of pharmacological therapy and c-ECT. c-ECT and m-ECT can reduce the time and cost, and the number of hospitalisations. At the same time, one of the major trends in ECT practice over the past 20 years has been the shift from inpatient to outpatient treatment. Conclusions: c-ECT and m-ECT are underutilised and understudied despite positive clinical experience spanning over 70 years. Although they are used all over the world, there are no specific guidelines or standardised methods for conducting this therapy. Studies that are currently underway should provide recommendations regarding the selection, frequency, and duration of c-ECT and m-ECT.

Safety of electroconvulsive therapy (ECT) in pregnancy: a systematic review of case reports and case series

Pregnancy and the immediate postpartum period are considered at high risk for women who have already received a previous psychiatric diagnosis and might represent a stressful event favoring the onset of new psychiatric disorders. The electroconvulsive therapy (ECT) is effective for the treatment of severe, treatment-resistant mental disorders, and it could represent a therapeutic choice for psychiatric conditions during pregnancy. The purpose of this systematic review is to evaluate the safety of ECT during pregnancy and to update the state of the art of its use. An extensive literature search on PubMed, APA PsycInfo, and Scopus databases for relevant articles published from inception to September 2023 has been performed. A final number of 45 articles (34 case reports and 11 case series, for a total of 130 pregnant women) were included in the present review. The limited evidence confirmed that ECT is effective in determining a partial remission of symptoms in women suffering from severe mental disorders, especially in the presence of suicidal ideation or psychosis, during all pregnancy epochs. However, ECT is not free from side effects, although the majority of possible complications were of low- or moderate-grade and not life-threatening for the women. Exposure to pharmacological treatment before or during the ECT or to the anesthetic during ECT might have contributed to the onset of these complications. ECT techniques evolved over years, increasing the degree of its safety, and according to our review it appears to be relatively safe and effective during pregnancy in the majority of cases.

Catatonia and ECT across the lifespan

Electroconvulsive therapy (ECT) is a safe and effective treatment for catatonia with high response rates. Although empirical data suggest that tolerability and efficacy are at least as good as in adults, ECT treatment of children, adolescents, and geriatric patients seems to pose a specific challenge for many practitioners. This article intends to explore and discuss reasons hindering the use of ECT in these patient groups, give an overview on the use of ECT to treat catatonia and provide practical advice on ECT in children, adolescents, and geriatric patients for the treatment of catatonia. Classification of catatonia as a subform of schizophrenia and a diagnostic overlap with other common conditions in children, adolescents, and geriatric patients might lead to underdiagnosis of catatonia. Concerns about the mechanism of action and about a lack of controlled studies as well as general concerns about the use of ECT in children and adolescents might lead to underutilization of ECT. However, studies of ECT to treat catatonia in children, adolescents, and geriatric patients consistently show its safety and effectiveness. Administration of ECT needs to consider some specific characteristics of children, adolescents, and geriatric patients. In conclusion, ECT is a safe and highly effective treatment for catatonia across the lifespan. Existing evidence does not warrant restrictions of its use in certain age groups.