The Effects of Remifentanil, Dexmedetomidine, and Metoral as Adjuncts to Thiopental on Hemodynamic Status After Electroconvulsive Therapy in Patients with Major Depressive Disorder: A Randomized Controlled Clinical Trial

Background

Depression is a prevalent mental disorder affecting more than 300 million people of all ages globally. Despite being the first-line treatment for depression, antidepressant medications are only effective for 60% - 70% of patients. Electroconvulsive therapy (ECT) is an effective treatment for severe cases, although it can result in short-term side effects.

Objectives

This study aimed to compare the effectiveness of remifentanil, dexmedetomidine, and metoral as premedications for ECT in patients with major depressive disorder (MDD).

Methods

In this prospective double-blinded randomized controlled clinical trial, a total of 120 MDD patients aged 18 - 60 were included. They were randomly assigned to receive remifentanil, dexmedetomidine, or metoral in combination with thiopental before ECT. Hemodynamic responses (mean arterial blood pressure, pulse rate, arterial blood oxygen saturation), seizure duration, recovery time, agitation scores, and patient satisfaction scores (reverse coded) were measured and compared.

Results

Dexmedetomidine exhibited superior hemodynamic control with lower mean arterial blood pressure (P < 0.001) and pulse rate (P < 0.001) than remifentanil and metoral. Patients receiving dexmedetomidine or remifentanil showed reduced agitation (P < 0.001) and better satisfaction than the metoral group (P < 0.001). Remifentanil displayed intermediate outcomes, while metoral exhibited the least favorable results. Seizure duration was not significantly different between the dexmedetomidine and remifentanil groups (P = 0.843).

Conclusions

Dexmedetomidine is considered the most satisfactory group due to the better control of blood pressure, heart rate, and agitation and better patient satisfaction despite the longer recovery time.

Electroconvulsive therapy for treating patients with agitation and related behavioral disorders due to dementia: a systematic review

Behavioral disturbances are clinically relevant in patients with dementia, and pharmacological regimens to mitigate these symptoms have provided limited results. Proven to be effective in several psychiatric conditions, electroconvulsive therapy is a potentially beneficial strategy for treating severe agitation due to dementia.

Objective

This review aimed to examine the publications on the efficacy, safety and tolerability of electroconvulsive therapy in treating patients with agitation due to dementia.

Methods

We performed a systematic analysis on the electroconvulsive therapy to treat patients with dementia and coexisting severe agitation. Articles were classified according to the level of evidence based on methodological design. Patients received an acute course of electroconvulsive therapy, often followed by maintenance intervention.

Results

We selected 19 studies (156 patients; 64.1% women; 51-98 years old), which met the inclusion criteria: one case-control study by chart analysis (level of evidence 2); one open-label study (level of evidence 3); three historical/retrospective chart analyses (level of evidence 4); and 14 case series/reports (level of evidence 5). No randomized, sham-controlled clinical trials (level of evidence 1) were identified, which represents the main methodological weakness. Some patients had postictal delirium, cardiovascular decompensation and cognitive changes, lasting for a short time.

Conclusions

Overall, patients achieved significant improvement in agitation. However, the main finding of the present review was the absence of methodological design based on randomized and sham-controlled clinical trials. Despite methodological limitations and side effects requiring attention, electroconvulsive therapy was considered a safe and effective treatment of patients with severe agitation and related behavioral disorders due to dementia.

Knowledge and Attitudes of First- and Final-Year Medical Students about Electroconvulsive Therapy: The Impact of Media

OBJECTIVE

The aim of this study is to evaluate medical students' knowledge about and attitudes towards electroconvulsive therapy (ECT) and to assess the impact of information sources (including those within and outside the curriculum) on knowledge and attitudes by comparing first- and final-year medical students.

METHODS

Two hundred and ninety-five first-year and one hundred forty-nine final-year medical students of the University of Leuven (KU Leuven) in Belgium responded to an anonymous self-administered survey which consisted of questions about sociodemographic background, self-perceived knowledge about medicine, psychiatry and ECT, interest in psychiatry, experience with psychiatric disorders, information sources of ECT, and knowledge about and attitudes towards ECT.

RESULTS

Compared to first-year medical students, final-year students had better knowledge about and more positive attitudes towards ECT, partially explained by differences in information sources. Nevertheless, both student groups showed an average knowledge score below 50%. Whereas freshmen attributed their knowledge to movies or documentaries, senior students gained knowledge mainly at university courses, scientific journals, and attending live ECT sessions. A significant positive correlation was found between knowledge about and positive attitudes towards ECT.

CONCLUSIONS

The knowledge of first- and final-year medical students remains limited, potentially due to limited instruction about ECT in medical courses. The use of media as an information source predicted negative attitudes towards ECT. Therefore, the stigma and misinformation provided in the media need to be addressed in the medical curriculum.

The superiority of ketofol and etomidate against propofol or thiopental anesthesia for ECT

OBJECTIVES

Most anesthetic drugs used for electroconvulsive therapy (ECT) have dose-dependent anticonvulsive effects, counter-acting seizure induction, lowering seizure quality. However, a consummate drug for ECT anesthesia has not yet been established. Therefore, in this study, we aimed to investigate the effects of etomidate, thiopental, propofol and co-administration of ketamine-propofol (ketofol) on seizure quality and hemodynamic safety.

METHODS

Registries of 121 patients (1077 sessions) were retrospectively evaluated. The effects of anesthetics on ECT-related parameters (stimulation charge, central seizure duration, number of failed stimulation trials, mean arterial pressure, and peak heart rate) were analyzed via linear mixed-effects models.

RESULTS

Overall, the seizure duration decreased, and the stimulation charge increased in time with continuing sessions within a course of ECT. The decrease in seizure duration and the increase in required stimulation charge was significantly lower with etomidate and ketofol. Additionally, ketofol was significantly related to a lower number of failed stimulation trials compared to propofol. Ketofol and propofol use was associated with a significantly lower postictal mean arterial pressure.

CONCLUSION

Ketofol and etomidate were equivalently superior in the rate of decrease in seizure duration and the required elevation in stimulus charge, which would interpret into valuable clinical guidance, especially for "seizure resistant" patients, and their use may potentially lower ECT related cognitive side effects.

Evaluating Factors Affecting the Time Interval Between Propofol Injection and Induction of Electro-convulsion and Relationship Between These Factors and Duration of Convulsion

Background

Current evidence on the effect of anesthetic-ECT time interval (AETI) is controversial. This study aimed to investigate the factors affecting the time interval between propofol injection and electro-convulsion induction and the relationship between these factors and the duration of convulsion.

Methods

In this study, 102 patients (616 sessions of ECT) were studied. Demographic and clinical data (age, gender, receiving or not receiving medications that affected the seizure threshold, the total number of ECT sessions, clinical severity of admission scores, clinical diagnosis, propofol dose, seizure duration, and AETI) were collected in special forms and analyzed by appropriate statistical methods.

Results

Sessions with long-term AETI had longer seizure time than sessions with short-term AETI (33.47 ± 8.46 vs. 28.68 ± 9.74, P value < 0.05). The duration of seizures was significantly longer in the group with long AETI in sessions 1, 2, and 4 than in the other group (P value < 0.05). There was a significant relationship between the duration of seizures and propofol dose, AETI, and receiving drugs effective in the seizure threshold (P value < 0.05).

Conclusions

The results showed that increasing AETI and injecting a lower dose of propofol to induce anesthesia would increase the duration of seizures. Also, taking medications that would affect the seizure threshold reduces the duration of seizures.

Long-term quality of life in treatment-resistant depression after electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is highly effective for treatment-resistant depression (TRD), and previous studies have demonstrated short-term improvements in quality of life (QoL) after ECT.  However, long-term QoL after ECT has not been studied, and the baseline patient characteristics that predict long-term QoL remain unknown.

METHODS

Seventy-nine subjects with unipolar or bipolar TRD were enrolled in this prospective longitudinal observational study. Physical, psychological, social, and environmental QoL domains were measured with the abbreviated World Health Organization Quality of Life scale (WHOQOL-BREF) at baseline and every 6 months for up to 2 years after ECT.  Baseline sociodemographic and clinical features were tested for association with long-term QoL.

RESULTS

Long-term follow-up data were available from 49 participants.  Relative to baseline, average psychological and physical QoL improved during the follow-up period (Hedges' effect size: 0.27-0.83).  About 40-50% of individuals experienced clinically meaningful improvement.  Subjects with better initial antidepressant response with ECT reported better QoL over the subsequent two years.  Long-term QoL improved most among individuals who were married, those without disability status, and those with psychotic features or shorter depressive episodes at baseline.

LIMITATIONS

Participants were from a single US academic center and mainly of European ancestry, so findings may not generalize to other settings or ethnicities.  The observational design does not allow causal inferences.

CONCLUSIONS

Long-term psychological and physical QoL outcomes vary widely after ECT. Individuals with the best outcomes are those who respond well to ECT initially, married people, and those with a less chronic course of illness.

The effect of risperidone and electroconvulsive therapy on corrected QT interval in electrocardiogram of psychiatric patients

BACKGROUND

Some types of antidepressants and antipsychotic medications have cardiovascular side effects that can be life-threatening. Electroconvulsive therapy (ECT) is capable of generating physiological stress and may lead to increased QT interval followed by arrhythmias. Risperidone can also increase the risk of arrhythmia by increasing the corrected QT (QTc) interval. Since many patients require co-administration of risperidone and ECT, this study aimed to investigate the concurrent effect of ECT and risperidone administration on the QTc interval.

METHODS

For this cross-sectional study, 60 patients (18-65 years) admitted in 22 Bahman Psychiatric Hospital (Qazvin, Iran) that were candidate for treatment with risperidone, ECT, or both methods were concurrently divided into three groups. The groups included patients treated with ECT, risperidone, and combination treatment (risperidone and ECT). At the beginning of the study, electrocardiogram (ECG) was obtained for all patients and QT was performed manually, and finally, QTc interval was measured two times for each group. Required information was collected through medical records. Then, inferential statistics, analysis of variance (ANOVA), was used to determine differences between different variables.

RESULTS

A significant increase in heart rate (HR) in the third group compared to first and second groups was observed. None of the treatments had a significant effect on QTc interval, but the QTc interval increased slightly in groups treated with the ECT alone and particularly, the ECT plus risperidone in comparison to the baseline values.

CONCLUSION

Our study showed that risperidone, ECT, and their concomitant combination did not affect the QTc interval. Therefore, risperidone and ECT are safe and their combination can also be a good option for refractory patients undergoing ECG monitoring and cardiopulmonary devices.

Cytokines changes associated with electroconvulsive therapy in patients with treatment-resistant depression: a Meta-analysis

One third of depressive patients do not achieve remission after several steps of treatment and are considered as treatment resistant. Electroconvulsive therapy (ECT) improves symptoms in 70 to 90% of such cases. Resistant depression is associated with a dysregulation of the immune system with a dysbalance between the pro- and the anti-inflammatory cytokines. Therefore, we aimed to measure the kinetic of cytokines levels before, during and at the end of ECT. To test this hypothesis, we performed a meta-analysis assessing cytokines plasma levels before, during and after ECT in patients with major depressive disorders. After a systematic database search, means and standard deviations were extracted to calculate standardized mean differences. We found that IL-6 levels increased after 1 or 2 ECT session (p = 0.01) then decrease after 4 ECT sessions (p < 0.01) with no difference at the end of ECT (p = 0.94). A small number of studies were included and there was heterogeneity across them. The present meta-analysis reveals that ECT induces an initial increase of IL-6 levels and a potential decrease of TNF-α levels. No changes on IL-4 and IL-10 levels were found. Further work is necessary to clarify the impact of ECT on peripheral cytokines.

Electroconvulsive Therapy in Mania: A Review of 80 Years of Clinical Experience

Resistance to pharmacological agents is commonly encountered in the treatment of acute episodes of mania. In contemporary practice guidelines, electroconvulsive therapy (ECT), once a widely used standalone intervention for mania, is no longer considered a first-line treatment. Stigma, logistics, and ethical factors constrain ECT administration in this condition and lead to its underutilization. However, the past three decades have produced promising research regarding the use of ECT in mania. Randomized controlled trials, albeit in limited numbers, the adoption of ultrabrief ECT, examination of the safety and efficacy of combining ECT with pharmacological agents, including lithium, and use of ECT as a maintenance strategy have enhanced our understanding of how and when to utilize this intervention in mania. In this comprehensive review, the authors summarize the evidence regarding the efficacy and safety of ECT in mania, including related syndromes, such as delirious mania and mixed affective states. The impact of technical parameters, particularly the choice of treatment frequency, electrode placements, and pulse width, are discussed in the light of recent evidence.

Electroconvulsive Therapy for a Patient with Suicide by Drinking Bleach During Treatment of COVID-19: A Case Report

Electroconvulsive therapy (ECT) was first experienced in 1938 and had been conducting without anesthesia for 30 years. In this study, the most common indication for ECT was mood disorder (major depressive disorder and bipolar I disorder). We introduce a patient with a history of COVID-19 and suicide who required emergency ECT. Electroconvulsive therapy can be life-saving in patients with suicide history or catatonic schizophrenia. Health workers are at the front line of the COVID-19 outbreak control and must follow health instructions. Aerosol-producing procedures such as suction in anesthesia for ECT may facilitate the transmission of infectious diseases such as COVID-19. When performing aerosol-producing procedures during the pandemic of novel coronavirus, every patient should be considered suspicious.

[Electroconvulsive Therapy: A Health Literacy Problem]

N/a.

ElectroConvulsive therapy Cognitive Assessment (ECCA) tool: A new instrument to monitor cognitive function in patients undergoing ECT

BACKGROUND

Electroconvulsive therapy (ECT) is a well-established treatment for severe depression but may result in adverse cognitive effects. Available cognitive screening instruments are nonspecific to the cognitive deficits associated with ECT. An ECT-cognitive assessment tool which can be easily administered was developed and validated in a clinical setting.

METHODS

One hundred and thirty-six participants were enrolled. The ElectroConvulsive therapy Cognitive Assessment (ECCA) and the Montreal Cognitive Assessment (MoCA) were administered prospectively to 55 participants with major depressive disorder (MDD) undergoing ECT at three time points: pre-treatment, before the sixth treatment and one-week post-treatment. The psychometric properties of the total and domain scores were evaluated at all three time points. Forty demographically comparable participants with MDD who did not receive ECT, and 41 healthy, age-matched controls were evaluated at a single time point.

RESULTS

ECCA and MoCA scores were not statistically different at baseline. Prior to the sixth and final ECT session, total ECCA scores were significantly lower than the MoCA total scores. The ECCA domains of subjective memory, informant-assessed memory, attention, autobiographical memory and delayed verbal recall were significantly lower post-ECT compared to pre-ECT.

LIMITATIONS

The ECCA was compared only to the MoCA rather than to a more comprehensive neuropsychological testing. This limitation reflected the real-life clinical burden of performing full neuropsychological testing at three time points during the treatment course.

CONCLUSIONS

The ECCA is a brief, reliable, bedside cognitive screening assessment tool that may be useful to monitor cognitive function in patients treated with ECT. The test can be downloaded from fuquacenter.org/ecca.

Electroconvulsive Therapy-Related Anxiety: A Survey in an Academic Hospital in the North of Iran

Background

Electroconvulsive therapy (ECT) is a medical treatment most commonly used in the most severe psychiatric diseases; however due to unreal anxiety, it is not widely accepted by patients and their families.

Objectives

The present study aimed to investigate the main causes of ECT-related anxiety (ERA) in an academic hospital in the north of Iran.

Methods

In this study, the participants were hospitalized psychiatric patients with proper communication skills. A 12-item questionnaire encompassing four sections (namely ECT side-effects, procedure factors, medical team communication, and familial, social, and economic factors) were filled out by a responsible psychiatric resident through a face-to-face interview. The participants’ demographic information, including gender, age, psychiatry disorder, level of education, and history of ECT, were also recorded.

Results

In this study, 353 cases were analyzed, among whom 329 patients (93.2%) reported at least one item for ERA, and 143 patients (85.6 %) had the history of ECT. All the participants (100%) had no experience in this regard (P = 0.0001). The most common cause of ERA was ECT-related side effects (70.7%) such as memory impairment (60.4%), disablement (24.9%), and death (14.7%) followed by procedure factors (27.2%), general anesthesia (GA) (73.2 %), and electric current (26.8 %). A significant relationship was observed between gender and the history of ECT with the patients’ anxiety reasons (P = 0.0001); however, the other variables, including age (P = 0.72), type of disease (P = 0.144), and the level of education (P = 0.012) had no impact on the results.

Conclusions

In this paper, the main causes of ERA were general anesthesia, memory impairment, and electric current. Obviously, a multidisciplinary approach is required to help these patients to handle their fear and anxiety successfully.

Comparison of Premedication with Low-Dose Midazolam Versus Etomidate for Reduction of Etomidate-Induced Myoclonus During General Anesthesia for Electroconvulsive Therapy: A Randomized Clinical Trial

Background

A variety of anesthetics including methohexital, thiopental sodium, propofol, ketamine, and etomidate are used for electroconvulsive therapy (ECT), each accompanied by adverse effects that can cause unpleasant experiences for patients. Etomidate-induced myoclonus is among the adverse effects. We attempted to assess the effect of premedication with low-dose midazolam compared to etomidate on the reduction of this complication.

Objectives

This study was designed to compare the effectiveness of low-dose etomidate and low- dose midazolam to suppress etomidate-induced myoclonus in ECT.

Methods

This randomized double-blinded clinical trial was conducted on 132 patients who were candidates for ECT. They were divided into three groups of 44 patients to receive 0.015 mg/kg midazolam, 0.03 mg/kg etomidate, or placebo. Independent t-test and chi-square test were used for comparison of variables.

Results

The frequency of myoclonic movements during anesthesia was different between the three groups (P value < 0.001). Myoclonic movements were significantly lower in the midazolam group than in the placebo (P value < 0.001) and etomidate (P value = 0.002) groups. In addition, the intensity of myoclonic movements was significantly higher in the midazolam group than in the placebo and etomidate groups (P value < 0.001).

Conclusions

Low-dose midazolam (0.015 mg/kg) before anesthesia induction with etomidate was accompanied with significantly lower incidence and intensity of myoclonus than low-dose etomidate (0.03 mg/kg).

The anaesthetic-ECT time interval with thiopentone-Impact on seizure quality

BACKGROUND

The time between anaesthetic induction and ECT stimulus administration has been hypothesised to significantly impact ictal EEG quality. In this study, our aim was to examine the effect of the time interval between anaesthetic induction and the ECT stimulus for ictal seizure quality in ECT sessions utilising thiopentone anaesthesia.

METHODS

413 EEG traces from 42 patients, collected retrospectively, were manually rated using a quantitative-qualitative structured rating scale (indices including seizure amplitude, regularity, post-ictal suppression and general seizure quality). Linear Mixed Effects Models were used to analyse the effect of the anaesthetic-ECT time interval on seizure quality indices, seizure duration and orientation scores after ECT, controlling for patient and ECT treatment factors.

RESULTS

The anaesthetic-ECT time interval had a significant impact on ictal EEG quality indices (p < 0.05), with longer times producing higher quality seizures. Seizure duration and orientation scores after ECT were not significantly influenced by the anaesthetic-ECT time interval. Age, anaesthetic dose, ECT type and ECT treatment number also had a significant impact on measures of seizure quality (p < 0.05).

LIMITATIONS

The effect of ventilation technique was not explicitly measured. Only manual ratings of ictal quality were analysed.

CONCLUSIONS

The time between anaesthetic induction and ECT stimulus administration has a significant impact on the ictal EEG seizure quality observed, with thiopentone anaesthetic. These results are consistent with prior findings with propofol anaesthesia, and suggest a need for routine clinical monitoring of this time interval. This variable warrants consideration when interpreting ictal EEGs, which often informs subsequent dosing decisions.

Catatonia Development in a Patient with Bipolar Disorder Following Electroconvulsive Therapy: A Case Report

Objective: Electroconvulsive therapy (ECT) is a major treatment of catatonia; and catatonia development during electroconvulsive therapy is a highly surprising phenomenon. We present a patient with bipolar disorder who developed catatonia during ECT. Case Reports : A 21-year-old woman, with a known case of bipolar disorder in manic phase without psychotic feature, history of long acting antipsychotic use, and severe B12 deficiency, was treated with ECT. Full catatonia syndrome developed after the fifth session of ECT. Conclusion: In rare cases, catatonia can develop during ECT course in the presence of some precipitating factors. Thus, these precipitating factors should be eliminated as much as possible before the start of ECT course to prevent catatonia development.

Effect of Adjuvant Electroconvulsive Therapy Compared to Antipsychotic Medication Alone on the Brain Metabolites of Patients with Chronic Schizophrenia: A Proton Magnetic Resonance Spectroscopy Study

Objective: Schizophrenia is a common psychiatric disease and is characterized by changes in several brain metabolites detectable by magnetic resonance spectroscopy (MRS). Electroconvulsive therapy (ECT) is a general method of management for most severe psychiatric conditions that may play a role in changing the brain metabolites. This study examined the effectiveness of adjuvant ECT with oral medication compared to that of oral second generation antipsychotic medication alone on brain metabolites in patients with chronic schizophrenia. Method : This study was conducted on 20 patients with chronic schizophrenia who were admitted to a hospital; of them, 10 underwent ECT as an adjuvant therapy with oral medication at least 8 times, and 10 patients were given a second- generation antipsychotic therapy drug (risperidone and olanzapine) without ECT for at least 4 weeks. MRS was used to assess brain metabolites, including N-acetyl aspartate (NAA), choline (Cho), creatine (Cr), myoinositol (MI), and Glx (glutamate [Glu] and glutamine [Gln]), in the left prefrontal cortex, left thalamus, left hippocampus, and left occipital cortex. Differences between the 2 groups were not significant, except for method of treatment. Results: The NAA/Cr ratio in the left prefrontal cortex was significantly higher in ECT-treated patients (P = 0.035). In addition, the Cho/Cr ratios in the left prefrontal cortex and left thalamus were statisticaly lower in the ECT-treated patients than those treated with oral antipsychotic drugs alone (P = 0.019). No statistically significant changes were observed between the 2 groups in other sites of the brain. In addition, no statistically significant differences were detected between the 2 groups in SAPS and DES scores. Conclusion: Compared to oral antipsychotic drug treatment, ECT had improving effects on at least 2 metabolites in the brains of patients with schizophrenia. Therefore, ECT may have a neuroprotective effect in these patients.

General Anaesthesia Protocols for Patients Undergoing Electroconvulsive Therapy: Retrospective analysis of 504 sessions over a five-year period at a tertiary care hospital in Oman

OBJECTIVES

This study aimed to review general anaesthesia protocols for patients undergoing electroconvulsive therapy (ECT) at a tertiary care hospital in Oman, particularly with regards to clinical profile, potential drug interactions and patient outcomes.

METHODS

This retrospective study took place at the Sultan Qaboos University Hospital (SQUH), Muscat, Oman. The electronic medical records of patients undergoing ECT at SQUH between January 2010 and December 2014 were reviewed for demographic characteristics and therapy details.

RESULTS

A total of 504 modified ECT sessions were performed on 57 patients during the study period. All of the patients underwent a uniform general anaesthetic regimen consisting of propofol and succinylcholine; however, they received different doses between sessions, as determined by the treating anaesthesiologist. Variations in drug doses between sessions in the same patient could not be attributed to any particular factor. Self-limiting tachycardia and hypertension were periprocedural complications noted among all patients. One patient developed aspiration pneumonitis (1.8%).

CONCLUSION

All patients undergoing ECT received a general anaesthetic regimen including propofol and succinylcholine. However, the interplay of anaesthetic drugs with ECT efficacy could not be established due to a lack of comprehensive data, particularly with respect to seizure duration. In addition, the impact of concurrent antipsychotic therapy on anaesthetic dose and subsequent complications could not be determined.

Electroconvulsive Therapy - What Do Patients Think Of Their Treatment?

BACKGROUND

The Regulation and Quality Improvement Authority (RQIA) monitors the administration of electroconvulsive therapy (ECT) in Northern Ireland (NI). As part of their inspection methodology RQIA wished to include feedback from ECT patients. The aim of this report is to summarise the opinions of ECT patients over a 1-year period and to compare their feedback about treatment with the standards of best practice, as defined by the Electroconvulsive Therapy Accreditation Service (ECTAS).

METHOD

RQIA was granted permission to use the ECTAS patient questionnaire. The questionnaire was distributed to all the ECT clinics in NI and staff were requested to give them to patients who had received a course of ECT.

RESULTS

A total of 42 individuals returned questionnaires, 24 females (57.1%) and 18 (42.9%) males. The response rate was 26%. Almost half of respondents were detained under the Mental Health (Northern Ireland) Order 1986 (n=19, 45.2%), with one third receiving ECT as a day patient (n=14, 33.3%). Respondents reported having detailed information about ECT, with ECTAS standards 4.2 and 4.3 being affirmed in over 80% of cases. Eighty percent of respondents (n=34) believed they benefited from ECT.

CONCLUSION

The results are mainly favourable towards ECT. The majority felt they benefited from treatment.

Is Conduct of Research in Electroconvulsive Therapy Ethical?

INTRODUCTION

Controversy surrounding ECT creates skepticism about the ethics of conducting ECT research. This paper discusses the ethical conduct of clinical research and then focus on the ethics as applied to ECT.

METHODS

PubMed was searched for articles related to the ethical conduct of research and that of ECT research published in English.

RESULTS

ECT research is ethically justified and should always continue to be conducted with the highest ethical standards. ECT research entails few ethical peculiarities such as involving multiple sessions were capacity to consent can change. It would be unethical not to conduct ECT research.

CONCLUSION

ECT research must be based on sound hypotheses in the presence of a clinical equipoise in well-designed studies. ECT studies must select a fair and non-biased sample of participants. It is important that participants represent the broad population of the people that would be receiving ECT for that specific indication. ECT research is ethical; and more research in this field could help decrease stigma and barriers to treatment, and/or reduce side effects and improve efficacy of a potentially life-saving intervention.

Economic evaluation of resistant major depressive disorder treatment in Iranian population: a comparison between repetitive Transcranial Magnetic Stimulation with electroconvulsive

BACKGROUND

It is estimated that major depression disorders constitute 8.2% of years lived with disability (YLDs) globally. The repetitive Transcranial Magnetic Stimulation (rTMS) and Electroconvulsive Therapy (ECT) are two relative common interventions to treat major depressive disorders, especially for treatment resistant depression. In this study the cost- effectiveness and cost-utility of rTMS were compared with ECT in Iranian population suffering from major depressive disorder using a decision tree model.

METHODS

A decision tree model conducted to compare the cost-effectiveness ratio of rTMS with ECT in a health system prospective and 7 months' time horizon. The outcome variables were: response rate, remission rate and quality-adjusted life-years (QALYs) of the rTMS and ECT as primary and secondary outcomes extracted from systematic reviews and randomized control trials. The costs were also calculated through a field study in one clinic and one hospital; the direct costs have only been considered.

RESULTS

The total cost for rTMS and ECTstrategieswere11015000Rials (373US$) and 11742700 Rials (397.7US$), respectively. Also the rTMS/ECT ratio of costs per improved patients was 1194410Rials (40.5 US$); the ratio for costs per QALYs utility was 21017139 Rials (711.72 US$). The incremental cost- effectiveness ratio of rTMS versus ECT was 1194410 Rials (40.44 US$) after treatment and maintenance courses.

CONCLUSION

Given the current prevalence of depressive disorders in Iranian population, the ECT is more cost-effective than TMS. The sensitivity analysis showed that if the prevalence of major depressive disorders declines to below 5% or the costs of rTMS decrease (rTMS provided by public sector), then the rTMS becomes more cost-effective compared with ECT. However, efficacy of rTMS depends on the frequency of pulsed magnetic field, the location of rTMS on the head, the number of therapeutic sessions and the length of each session.

Supportive Nursing Care and Satisfaction of Patients Receiving Electroconvulsive Therapy: A Randomized Controlled Clinical Trial

Background:

Patient satisfaction is the most important criterion in evaluating the quality of care. Besides, its assessment in patients with severe mental disorder treated by electroconvulsive therapy (ECT) is highly appropriate. The ECT is accompanied by lower satisfaction and may exacerbate the patients’ condition.

Objectives:

The current study aimed to determine the effect of supportive nursing care on the satisfaction of patients receiving ECT.

Patients and Methods:

This randomized controlled trial was conducted in the education center of Baharan psychiatric hospital, Zahedan, Iran. Seventy hospitalized patients receiving ECT were randomly divided into two groups of control (n = 35) and intervention (n = 35).The socio-personal and Webster Satisfaction Questionnaire were used as data collection tools. The intervention group received supportive nursing care by nurses trained in informational, emotional, and physical aspects. The control group received only regular nursing care. The levels of satisfaction were measured and compared between groups, before and after the intervention. Data were analyzed using the SPSS software, and Chi-square, independent and paired t tests, as well as covariance analysis were performed.

Results:

The results showed similarities in socio-personal characteristics of both groups. However, there was a significant difference (P < 0.001) between the means of satisfaction in the groups, predominantly for the intervention group. In other words, a significant difference (P < 0.001) was observed between the means of satisfaction of the intervention (54.71 ± 5.27) and control (36.28 ± 7.00) groups after intervention by controlling the effect of socio-personal variables.

Conclusions:

Results of the current study confirmed the effect of supportive nursing care on increasing the level of satisfaction in ECT receiving patients, recommending the use of this therapeutic method.

Antidepressant Effect of Combined Ketamine and Electroconvulsive Therapy on Patients With Major Depressive Disorder: A Randomized Trial

BACKGROUND

One of the shortcomings of the available treatments for major depressive disorder (MDD) is the time delay between starting the treatment and achieving an antidepressant response.

OBJECTIVES

We aimed to determine the effect of Ketamine as a synergistic antidepressant and anesthetic agent on MDD in electroconvulsive therapy (ECT).

PATIENTS AND METHODS

Twenty-two patients with MDD received Ketamine and Propofol as anesthetic agents compared with 20 patients as the control group who received Propofol in a double-blind randomized clinical trial. The Hamilton rating scale for depression was used to determine the changes in symptoms severity during ECT and a 2-week follow-up.

RESULTS

Both groups showed a reduction in depression severity, but there was no significant difference between the groups in the recovery process (P = 0.92). However, the cognitive performance recovery time in the Ketamine group was lower than that in the control group (P = 0.042).

CONCLUSIONS

This study could not show the effect of Ketamine on depression recovery in a 2-week follow-up period. Nevertheless, Ketamine may provide a better cognitive performance in patients under ECT.

A Case Report of Prolonged Apnea during ECT in a Patient with Suicidal Attempt by Organophosphorus Poison

Organophosphorus pesticides have been used in some cases for suicidal attempts. Such poison can affect plasma cholinesterase activity. The case was a 47-year-old man hospitalized due to suicide attempt with swallowing agricultural poison. The patient, diagnosed with major depressive disorder (MDD), underwent treatment with electroconvulsive therapy (ECT). At the first ECT session, the patient developed apnea for 45 minutes following receiving 20 mg succinylcholine. The patient was intubated; after restoration of respiration depth and rate, the patient was extubated. Collectively, in cases with history of suicide attempts, taking organophosphorus pesticides should be warn for pre-ECT anesthesia.

Shocking waves at the museum: the Bini-Cerletti electro-shock apparatus

The historian of science, Lorraine Daston, has written about things that talk. But how much can an artefact in a museum communicate its history to the public? Artefacts in museums speak, but it is not necessarily, or even at all, in the language of their original time and place. Cultural baggage, memories, and imagination all come into play, including those held by museum curators, and not least those contained within the operational and historical frameworks of such institutions. At the Museo di Storia della Medicina della Sapienza at the University of Rome we are organising an exhibition around an artefact that more than any other elicits emotive reactions – the Bini–Cerletti apparatus for the administration of electro-shock. This prototype of the first ECT machine, along with various historical documents, manuals, and textbooks relating to it, is a valued part of the Museo's collection. We are proud of it, yet as a display item, it is also something of golden chalice. Leaving aside the ethical question of whether we can (or should) convey to visitors the anxiety and pain of the patients who once submitted to the device, and leaving aside the different loads of historical and contemporary baggage that visitors will bring to it, how can such an object be represented in an historically honest way? This is the problem, for while we might be true to the context of its emergence, within that context (of Fascist Italy) the Bini–Cerletti apparatus was at one and the same time a blessing, a hope, a lie, and a profitable commercial product.

Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy

BACKGROUND

While electroconvulsive therapy (ECT) in major depression is effective, cognitive effects limit its use. Reducing the width of the electrical pulse and using the right unilateral electrode placement may decrease adverse cognitive effects, while preserving efficacy.

METHODS

In a double-masked study, we randomly assigned 90 depressed patients to right unilateral ECT at 6 times seizure threshold or bilateral ECT at 2.5 times seizure threshold, using either a traditional brief pulse (1.5 ms) or an ultrabrief pulse (0.3 ms). Depressive symptoms and cognition were assessed before, during, and immediately, two, and six months after therapy. Patients who responded were followed for a one-year period.

RESULTS

The final remission rate for ultrabrief bilateral ECT was 35 percent, compared with 73 percent for ultrabrief unilateral ECT, 65 percent for standard pulse width bilateral ECT, and 59 percent for standard pulse width unilateral ECT (all P's<0.05 after covariate adjustment). The ultrabrief right unilateral group had less severe cognitive side effects than the other 3 groups in virtually all primary outcome measures assessed in the acute postictal period, and during and immediately following therapy. Both the ultrabrief stimulus and right unilateral electrode placement produced less short- and long-term retrograde amnesia. Patients rated their memory deficits as less severe following ultrabrief right unilateral ECT compared to each of the other three conditions (P<0.001).

CONCLUSIONS

The use of an ultrabrief stimulus markedly reduces adverse cognitive effects, and when coupled with markedly suprathreshold right unilateral ECT, also preserves efficacy. (ClinicalTrials.gov number, NCT00487500.).

Proteomic analysis of rat brains following exposure to electroconvulsive therapy

Electroconvulsive therapy (ECT) is one of the most effective treatments used in psychiatry to date. The mechanisms of ECT action, however, are the least understood and still unclear. As a tool to elucidate the mechanisms of action of ECT, we employed proteomic analysis based on the identification of differentially expressed proteins after exposure to repeated ECT in rat brains. The expression of proteins was visualized by silver stain after two-dimensional gel electrophoresis. Of 24 differentially expressed protein spots (p<0.05 by Student t-test), six different proteins from 7 spots were identified by matrix-assisted laser desorption/ionization time-of flight (MALDI-TOF)/mass spectrometry. Among the identified proteins, there were five dominantly expressed proteins in the ECT-treated rat brain tissues (p<0.05); S100 protein beta chain, 14-3-3 protein zeta/delta, similar to ubiquitin-like 1 (sentrin) activating enzyme subunit 1, suppressor of G2 allele of SKP1 homolog, and phosphatidylinositol transfer protein alpha. The expression of only one protein, ACY1 protein, was repressed (p<0.05). These findings likely serve for a better understanding of mechanisms involved in the therapeutic effects of ECT.