Clinical Neuroscience of ECT (CNECT)

New on PubMed is this important review article with well-known ECT experts Bill McDonald and Bob Greenberg as senior authors: The Efficacy and Safety of Concomitant Psychotropic Medication and Electroconvulsive Therapy ( ECT ). Janjua AU, Dhingra AL, Greenberg R, McDonald WM. CNS Drugs . 2020 Apr 27. doi: 10.1007/s40263-020-00729-1. [Epub ahead of print] Review. PMID:   32342484 The pdf is here . Questions about concomitant medications comprise the most commonly asked questions of ECT practitioners  by both patients and referring health care providers. Which medicines to stop, which to taper,  which to  hold just the night before treatment, which to add. This  is a comprehensive   review of the old and new literature on this topic. Data for each  class of relevant psychotropic medications are presented, with summary conclusions for practical guidance.  Good reading for practitioners and trainees alike, a...

Recently out on PubMed, from Taiwan, is this case report of successful ECT for a variant of TD, tardive tremor: Successful Electroconvulsive Therapy for a 74-year-old Female with Major Depressive Disorder and Tardive Tremor: A Case Report and Literature Review. Yeh JY, Chiu NM, Chang YY, Lin PY, Lee Y. Clin Psychopharmacol Neurosci . 2020 May 31;18(2):331-336. doi: 10.9758/cpn.2020.18.2.331. PMID:   32329314   The pdf is here . In addition to the case report, there is a literature review of ECT for tardive movement disorders. The authors conclude that ECT was successful in about 75% of the reports. This case report is not well presented; the ECT details are particularly chaotic. One also wonders whether the patient would have fared better had she initially been treated with  ECT 15 years earlier, and never been exposed to the neuroleptics that caused her TD. In the bigger picture, the most important movement disorder for whic...

Today, "Classics in ECT" presents this landmark paper by Max Fink and Jan Otto Ottosson from 40 years ago: A theory of convulsive therapy in endogenous depression: significance of hypothalamic functions. Fink M , Ottosson JO. Psychiatry Res . 1980 Mar;2(1):49-61. PMID:   6106253 The pdf is here . The neuroendocrine theory of the mechanism of action of ECT (as it is generally referred to) remains  cogent and relevant today, among the few other competing, and complementary theories.  This paper harkens back to the time when the dexamethasone suppression test (DST) nearly became the first  laboratory diagnostic test in Psychiatry. Whether its failure was mainly political or scientific is debated to this day.

Out on PubMed today is this small case series from Japan: Electroconvulsive therapy in patients with cerebral aneurysms taking an anticoagulant or antiplatelet-report on three cases and review of the literature.  Hirata T, Yasuda K, Uemura T, Ueda T, Aruga Y, Shioe R, Tamaoki T, Suzuki T. Psychiatry Res. 2020 Apr 19;288:113022. doi: 10.1016/j.psychres.2020.113022. [Epub ahead of print] No abstract available. PMID: 32335467 The pdf is here . The report describes safe ECT in 3 patients with small, incidental cerebral aneurysms who were on concurrent anticoagulation (this was stopped in one of the 3). The letter-to-the editor is short on details of the treatments; there is no mention of blood pressure control strategies, for example. Such case reports and the accompanying literature review are helpful resources for partitioners when treating patients with  known cerebral aneurysms. Given the number of patients who have likely been treated with unknown small, cerebral an...

Out on PubMed today is another case report of anti-NMDA receptor encephalitis: 133 Toxic Psychosis: Follow-up After One Year of Treatment. Oriaifo G. CNS Spectr . 2020 Apr;25(2):284. doi: 10.1017/S1092852920000498. PMID:   32331009 The pdf is here . The salient features of this report include the successful treatment of catatonia with ECT (the patient had various immunotherapies and oophorectomy, as well), and the return to baseline functioning at one year followup. It is not clear why this is labeled "Toxic Psychosis," but the case, a published abstract, adds to the literature on anti-NMDA receptor encephalitis.

Out on PubMed today is a report of ECT for postpartum manic psychosis: Continuous electroconvulsive therapy for a patient with recurrent post-partum psychosis. Inagawa Y, Okada T, Yasuda M, Sato K, Watanabe R, Kawai T, Umino M, Inoue K, Suda S. Asian J Psychiatr. 2020 Apr 7;51:102078. doi: 10.1016/j.ajp.2020.102078. [Epub ahead of print] No abstract available. PMID: 32330689 The pdf is here . The title should actually say "Continuation" ECT, not "Continous" ECT. The report reminds us of the seriousness of postpartum depression and psychosis, and the important role of ECT in the treatment of these illnesses. Select item 32329314

Out on PubMed today is an article from colleagues at Yale and the Medical College of Georgia about the ECT consent process for minority patients:  Achieving Equity in Informed Consent: A Culturally-Informed Perspective for the Consideration and Consent of Minority Patients for Electroconvulsive Therapy. Parker CB, McCall WV, Rosenquist P, Cortese N, Spearman-McCarthy EV. Am J Geriatr Psychiatry . 2020 Apr 2. pii: S1064-7481(20)30273-6. doi: 10.1016/j.jagp.2020.03.009. [Epub ahead of print] PMID:   32321667 The pdf is here . This important commentary reminds us that minority patients are underrepresented in ECT populations and that a culturally informed perspective on the part of the ECT team is needed in the informed consent process for minority patients, particularly geriatric minority patients. In the words of the authors: What is the meaning of the finding?   — Reducing healthcare disparities for elderly minority patients in ECT re...

Out on PubMed today is a review article in The Medical Letter on Drugs and Therapeutics about antidepressant medications that mentions ECT: Drugs for Depression. [No authors listed] Med Lett Drugs Ther . 2020 Feb 24;62(1592):25-32. No abstract available.  PMID:   32320387 The pdf is here . Although ECT is only briefly mentioned in the text, one of the bullet points on the front page of the article is: "Electroconvulsive therapy (ECT) has the highest rates of response and remission of any form of antidepressant therapy." This article has 2 large tables that are excellent sources of drug comparisons, with dosing and side effect/metabolism information. It is a good reference to have available.

Today's blog post, suggested by Max Fink, features a case report from Australia of a rare cause of catatonia: Clozapine withdrawal malignant  catatonia  in a medical intensive care unit setting. Brailey J, Bastiampillai T. Asian J Psychiatr . 2020 Mar 30;52:102043. doi: 10.1016/j.ajp.2020.102043. [Epub ahead of print] No abstract available.  PMID:   32311586 The pdf is here . A review by Lander et al. in Translational Psychiatry in 2018 covered withdrawal catatonia from benzodiazepines as well as clozapine. One of the interesting findings was that ECT was not always a successful treatment for clozapine withdrawal catatonia, and that reinstitution of clozapine was required in some cases. The pdf is here .

Out on PubMed today is an editorial by Tom Birkenhager and Linda vanDiermen that accompanies an article in the current issue of Acta Psychiatrica Scandinavica written by myself, Jasmien Obbels and Pascal Sienaert ( When to Consider ECT ): Electroconvulsive  therapy: we are hesitant to use the most effective treatment for severe depression. Birkenhager TK, van Diermen L. Acta Psychiatr Scand . 2020 Apr;141(4):301-303. doi: 10.1111/acps.13171. No abstract available.  PMID:   32311077 The pdf is here . Drs. Birkenhager and vanDierman conclude with: Hopefully, the review by Kellner et al. ( 2 ) can reduce some of the hesitation felt by treating psychiatrists and authors of guidelines. It could help to reduce the negative influence of stigma by educating its readers. Actually, we suggest that psychiatrists who treat patients with mood disorders or psychotic disorders as well as all residents in psychiatry should read this paper. They are the on...

Today's post is about an airway management work around ( apneic  oxygenation) during the COVID-19 pandemic. This was shared on the ISEN listserv by Brian Espinoza of Arizona, and was  written  by an anesthesiologist he works with.  The idea is to avoid bagging the patient, so as not to spread secretions and virus particles Obviously this will not work on everyone, but it works on the majority as we've seen. After placement of ASA monitors, high flow nasal cannula oxygen is administered for several minutes, with the patient coached immediately prior to induction to ventilate deeply via the nose several times. Immediately upon induction, the oxygen is increased from 6 or 8 l/minute to 10, and the nares are pinched shut while pushing the cannula up against the nasal septum. This forces oxygen through the airway. I typically use my right hand to do that while using my left to chin lift. My objective is to maintain an open airway, allowing the flow of oxygen acc...

Out on PubMed yesterday was this article from an international group of anesthesiologists: Neuroanesthesia Practice During the COVID-19 Pandemic: Recommendations from Society for Neuroscience in Anesthesiology & Critical Care (SNACC).  Flexman AM, Abcejo A, Avitisian R, De Sloovere V, Highton D, Juul N, Li S, Meng L, Paisansathan C, Rath GP, Rozet I. J Neurosurg Anesthesiol. 2020 Apr 15. doi: 10.1097/ANA.0000000000000691. [Epub ahead of print] PMID: 32301764 The pdf is here . There is a 3-page section of recommendations on how to handle ECT during the COVID-19 pandemic. There has been a tremendous amount of discussion about this issue on the ISEN listserv and already in the published literature, with considerable variability in the recommendations. I offer this post today not to endorse all of these specific recommendations, merely to make them easily available for readers.

Out on PubMed today is a review article from ECT experts in Australia and New Zealand: Cognitive side-effects of electroconvulsive therapy: what are they, how to monitor them and what to tell patients.  Porter RJ, Baune BT, Morris G, Hamilton A, Bassett D, Boyce P, Hopwood MJ, Mulder R, Parker G, Singh AB, Outhred T, Das P, Malhi GS. BJPsych Open. 2020 Apr 17;6(3):e40. doi: 10.1192/bjo.2020.17. PMID: 32301408 The pdf is here . This article reviews the literature on cognition in ECT, makes recommendations about how to discuss this issue in the consent process and how to monitor patients during treatment. Although there is nothing new here, it is nonetheless a useful contribution to the literature. Please see also the blog post from 3/29/2020 about a new beside cognitive screening tool, the ECCA.

Out on PubMed today is this letter-to-the-editor  in Clinical Neurophysiology from researchers at Columbia University: Smaller increase in delta post-ictal suppression in magnetic seizure therapy than  electroconvulsive therapy in geriatric patients with severe depression: A multi-case study. Rowny SB, Kluisza L, Prudic J, Ly MT, Chen CM, Casal-Roscum L. Clin Neurophysiol . 2020 Mar 12;131(6):1219-1220. doi: 10.1016/j.clinph.2020.03.001. [Epub ahead of print] No abstract available.  PMID: 32299005 The pdf is  here . This is a post-hoc analysis of EEG data from 6 patients (3 MST, 3 RUL-UBP ECT), with clinical vignettes to demonstrate the antidepressant efficacy of MST with a favorable side-effect profile. The EEG findings included: "Specifically, MST responders showed smaller or no increases from start to end of treatment in delta post-ictal suppression, while ECT responders showed greater increases in delta post-ictal suppression." ...

Out on PubMed today is a review article from colleagues in Georgia about geriatric patients seen by C/L services; it has a very good section on ECT:  Considerations and Current Trends in the Management of the Geriatric Patient on a Consultation-Liaison Service.  Glass OM, Hermida AP, Hershenberg R, Schwartz AC. Curr Psychiatry Rep. 2020 Apr 13;22(5):21. doi: 10.1007/s11920-020-01147-2. Review. PMID: 32285305 The pdf is here . This review mainly covers delirium, dementia and depression. The separate section on ECT, although short,  appropriately  highlights the important role for ECT in the treatment of severe depression, particularly psychotic depression. One of the authors, Dr. Adriana Hermida from Emory University, is among those who are researching ECT for the treatment of  agitation  and other behavioral disturbances in dementia.

Out on Pubmed today is another important neuroimaging study from the Global ECT-MRI Research Collaboration (GEMRIC):  Structural changes induced by electroconvulsive therapy are associated with clinical outcome.  Mulders PCR, Llera A, Beckmann CF, Vandenbulcke M, Stek M, Sienaert P, Redlich R, Petrides G, Oudega ML, Oltedal L, Oedegaard KJ, Narr KL, Magnusson PO, Kessler U, Jorgensen A, Espinoza R, Enneking V, Emsell L, Dols A, Dannlowski U, Bolwig TG, Bartsch H, Argyelan M, Anand A, Abbott CC, van Eijndhoven PFP, Tendolkar I. Brain Stimul. 2020 Feb 21;13(3):696-704. doi: 10.1016/j.brs.2020.02.020. [Epub ahead of print] PMID: 32289700 The pdf is here . Data are from scans of 192 patients (120 responders, 72 non responders). The study looks at two things: structural changes related to treatment response and to electrode placement. They show 75% accuracy to classify treatment response (sensitivity 84%, specificity 60%). Increased volumes of right precuneus, right suprama...

Out on PubMed today is this study from Iran: 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.  Nazemroaya B, Mousavi SM. Anesth Pain Med. 2019 Dec 23;9(6):e94388. doi: 10.5812/aapm.94388. eCollection 2019 Dec. PMID: 32280614 The pdf is here . Optimizing ECT anesthesia is a very important part of contemporary ECT practice. Etomidate is one of several induction agents commonly used in ECT. Its advantages include low anticonvulsant properties and good hemodynamics. It does cause myoclonus in a substantial proportion of patients soon after injection. It is not clear that this is a major problem, other than possibly being confused with seizure activity. In this study, pretreatment with low-dose midazolam decreased the incidence and severity (there is a mistake in the abstract, contradicting this) of myoclon...

Out on PubMed today is this case report, useful for practitioners: Safe and Successful Treatment of Depression with Electroconvulsive Therapy in a Patient with Implanted Spinal Cord Stimulators.  Chen L, Peterson E, Wong G, Hui R, Fitzgerald PB. Brain Stimul. 2020 Apr 9. pii: S1935-861X(20)30083-8. doi: 10.1016/j.brs.2020.04.004. [Epub ahead of print] No abstract available. PMID: 32278713 The pdf is here . It is helpful to have reports such as this of the safe administration of ECT in patients with implanted spinal cord stimulators. This patient had both cervical and lumbar stimulators. While there is no serious reason to believe that such stimulators would pose a risk during ECT, it is reassuring to have actual clinical data of safe and effective ECT in this circumstance. This leads to a larger discussion of the use of ECT for depression in the context of chronic pain, and for the use of ECT to target chronic pain itself, for which there is some encouraging literature.

Today's post continues our series, "Classics in ECT", with what is likely the first report of the treatment of Parkinson's Disease (PD) with ECT. It is from the Tulane University School of Medicine in 1959: Observations on the effect of electroshock treatment on patients with parkinsonism. FROMM GH. Bull Tulane Univ Med Fac . 1959 Feb;18(2):71-3. No abstract available.  PMID:   13629283 The pdf is here . Short on details, this is nonetheless a very interesting historical document. I thank Dr. Pascal Sienaert for bringing it to my attention. Most ECT practitioners today know that ECT has significant beneficial effects on both the core motor symptoms and associated behavioral symptoms of PD. That this indication for ECT has been so little studied in controlled trials is quite unfortunate, in my opinion.

Today "Classics in ECT" brings you the prototype of neuroimaging studies in ECT,  done by Ed Coffey and colleagues from Duke, published in the Archives of General Psychiatry in 1991: Arch Gen Psychiatry.  1991 Nov;48(11):1013-21. Brain anatomic effects of electroconvulsive therapy. A prospective magnetic resonance imaging study. Coffey CE 1 ,  Weiner RD ,  Djang WT ,  Figiel GS ,  Soady SA ,  Patterson LJ ,  Holt PD ,  Spritzer CE ,  Wilkinson WE . The pdf is here . 35 inpatients for had brain scans before, 2-3 days, and 6 months after ECT. There were no significant differences in volumes of various brain regions. The authors concluded: "Our results confirm and extend previous imaging studies that also found no relationship between ECT and brain damage." The tremendous  importance of this study was that it confirmed that ECT does not cause deleterious brain structural changes, often referred to by critics o...

Here is an editorial from two psychiatrists in New Zealand about the recent Sigstrom study of subjective memory and ECT (see blog post of 3/10/2020): Subjective memory impairment after electroconvulsive therapy - potentially modifiable? Eggleston K, Porter R. BJPsych Open. 2020 Apr 6;6(3):e38. doi: 10.1192/bjo.2020.20. PMID: 32248868 The pdf is here . This editorial is worth reading because of its even-handed treatment of the issue of cognitive effects of ECT. It underscores the point of the importance of setting realistic expectations in the informed consent process, neither exaggerated nor down-played, of the largely transient cognitive effects of ECT.

"Classics in ECT" returns today with a wonderful exchange of letters-to-the-editor in Lancet 1994-1995. Here are the 3 letters in response (Kellett, Chatterjee and Fink) to a scurilous screed by one Tony Baker (below), asking for ECT to be banned in children. Electroconvulsive therapy. Fink M.  Lancet. 1995 Feb 25;345(8948):519. No abstract available. PMID:  786189 The pdf is here . ECT and young minds. Baker T.  Lancet. 1995 Jan 7;345(8941):65. No abstract available. PMID: 7799725 The pdf is here . The 3 letters in response, taken together, are an eloquent defense of and explanation of the benefits  of ECT.

Out on PubMed is this thoughtful case report about unsuccessful ECT in a patient with severe anorexia nervosa (AN): Failure of Electroconvulsive Therapy to Improve Anorexia Nervosa in the Absence of Other Psychiatric Comorbidities: A Case Report. Duriez P, Maatoug R, Verbe J. J ECT . 2020 Mar 31. doi: 10.1097/YCT.0000000000000678. [Epub ahead of print] No abstract available.  The pdf is here . There is a small literature about ECT for patients with eating disorders, with and without, other co-morbid psychiatric conditions.  This literature was summarized last year in JECT: The Use of Electroconvulsive Therapy in Eating Disorders: A Systematic Literature Review and Case Report. Pacilio RM, Livingston RK, Gordon MR. J ECT . 2019 Dec;35(4):272-278. doi: 10.1097/YCT.0000000000000599. The pdf is here . ECT can be life-saving for patients with AN and severe depression, and possibly for some with severe AN without clear-cut depressive illness,...

Don't believe everything you read in the medical literature, particularly when the message is to dismiss  or discredit ECT.  Successful replacement of  electroconvulsive  treatment (ECT) with transcranial direct current stimulation (tDCS) in severe, treatment-refractory catatonic schizophrenia: Case study. Wysokiński A. Schizophr Res . 2020 Apr 2. pii: S0920-9964(20)30171-7. doi: 10.1016/j.schres.2020.03.060. [Epub ahead of print] No abstract available.  PMID:   32249124 The pdf is here . This case report is replete with inaccuracies and unlikely conclusions. To label it "anecdotal" is too kind. While I do not question the good intentions of the author, the unfortunate consequence of such reports may be to promote unsubstantiated treatments for seriously ill patients.

Out on PubMed is this letter-to-the-editor from JECT: Effect of Extended Release Bupropion on Unilateral Ultrabrief Electroconvulsive Therapy Seizure Parameters in Major Depressive Disorder. Rakesh G, Mischel NA, Gunderson-Falcone G, Anderson A, Copeland D, Szabo ST, Weiner RD. J  ECT . 2020 Mar 31. doi: 10.1097/YCT.0000000000000679. [Epub ahead of print] No abstract available.  PMID:   32243338 The pdf is here . These investigators, most of whom are from Duke, present a pilot study with 10 patients, testing augmentation of ECT with bupropion. The idea is that concomitant use of an antidepressant might enhance/speed up antidepressant effect, and that, additionally, a putative pro-convulsant antidepressant might enhance seizure quality. The results were inconclusive, but the authors suggest that a larger trial is warranted, and they are probably correct.

Sheltering in place during the COVID-19 pandemic means that many people will be reading more, including rediscovering some of the classics. Sylvia Plath's autobiographical novel, The Bell Jar , includes perhaps the second most famous depiction of ECT in literature. Below are two citations about the book and Plath's struggle with depression. Electroconvulsive Therapy (ECT) in Literature: Sylvia Plath's The Bell Jar Charles H Kellner   1 Prog Brain Res 206, 219-28 2013 PMID:  24290484     Sylvia Plath's well-known novel, The Bell Jar, recounts her experience of a severe depressive episode. In the novel, the protagonist is treated with electroconvulsive therapy (ECT), as was Plath in life. The first ECT is given in the now-obsolete "unmodified" form, without general anesthesia. Later in the story, she receives ECT again, this time with full general anesthesia and muscle relaxation, as is the standard of care today, and recovers completely. Th...

William V. McCall, Editor-in-Chief of the Journal of ECT, has made available on open access three articles about ECT during the COVID-19 pandemic. They can be accessed via this link: https://journals.lww.com/ectjournal/pages/default.aspx One is a description of the experience of running an ECT service in Singapore during the pandemic, one is an editorial about ECT being an essential treatment, and one is a photograph (for "Images in Clinical ECT") of an ECT team in full protective equipment. ECT  in a time of COVID-19. Tor PC, Phu AHH, Koh DSH, Mok YM. J  ECT . 2020 Mar 31. doi: 10.1097/YCT.0000000000000690. [Epub ahead of print] No abstract available.  PMID:   32243336 Similar articles The pdf is here . Select item 32243335 ECT : An Essential Medical Procedure. Espinoza RT, Kellner CH, McCall WV. J  ECT . 2020 Mar 31. doi: 10.1097/YCT.0000000000000689. [Epub ahead of print] No abstract available.  PMID:   ...

Today's post continues our series, "Classics in ECT" with a commentary by Max Fink and Mickey Taylor from 2007: Electroconvulsive therapy: evidence and challenges. Fink  M,  Taylor  MA. JAMA . 2007 Jul 18;298(3):330-2. No abstract available.  PMID:   17635894 The pdf is here . The article is a concise review of the state of ECT in 2007, with a focus on comparing the CORE and Columbia University studies. It is clear, to-the-point, and remarkably relevant for ECT practice 13 years later. It reached a very wide audience since it was published in JAMA rather than a specialty psychiatry journal. I hope you will all read it, it will be time well spent.

Today's post is a simple reminder that ECT is an essential procedure for some of our most seriously ill and vulnerable patients. In the current very difficult climate of limited resources and cancellation, for safety purposes, of elective medical/surgical procedures, APA has stated that ECT is an essential  procedure (see Inpatient Psychiatric Settings ): https://www.psychiatry.org/psychiatrists/covid-19-coronavirus/practice-guidance-for-covid-19

Out on PubMed today is an overview article on ECT in pregnancy, from OB-GYN physicians at the Mayo Clinic and Duke: Electroconvulsive Therapy in Pregnancy: Safety, Best Practices, and Barriers to Care Sherrill Rose   1 ,  Sarah K Dotters-Katz   2 ,  Jeffrey A Kuller   3 Obstet Gynecol Surv, 75 (3) , 199-203 Mar 2020 PMID:  32232498 The pdf is here . This is an excellent presentation  of the topic, with literature review and reasonable recommendations.  ECT practitioners should read this article in full and recommend it to trainees.