Clinical Neuroscience of ECT (CNECT)

Out on PubMed today are these 2 review articles from the Child and Adolescent Psychiatric Clinics of North America. Authors include noted child psychiatrists Lee Wachtel and Neera Ghaziuddin from Johns Hopkins University and the University of Michigan, respectively: Use of Electroconvulsive Therapy in Autism. Park SE, Grados M, Wachtel L, Kaji S. Child Adolesc Psychiatr Clin N Am. 2020 Jul;29(3):455-465. doi: 10.1016/j.chc.2020.03.003. Epub 2020 May 5. PMID:  32471595 From the abstract: ECT is a treatment that can safely and rapidly resolve catatonia in autism and should be considered promptly. The literature available for ECT use in youth with autism is consistently growing. Under-recognition of the catatonic syndrome and delayed diagnosis and implementation of the anticatatonic treatment paradigms, including ECT, as well as stigma and lack of knowledge of ECT remain clinical stumbling blocks. Catatonia in Patients with Autism Spectrum Disorder. Ghaziuddin N, Andersen L, G

Out on PubMed recently is this epidemiological study of ECT use from researchers at the Mass General: Demographics of Patients Receiving Electroconvulsive Therapy Based on State-Mandated Reporting Data. Luccarelli J, Henry ME, McCoy TH Jr. J ECT. 2020 May 22. doi: 10.1097/YCT.0000000000000692. Online ahead of print. PMID:  32453188 The abstract is at the above link, and copied here: Objectives : Electroconvulsive therapy (ECT) is an effective treatment of depression and other psychiatric conditions. There are few comprehensive data on how many patients receive ECT in the United States or about the demographics of ECT recipients. This study characterizes the demographics of those receiving ECT and how these demographics may have changed with time. Methods: Freedom of information requests for all data from record keeping inception to January 2019 were sent to the Department of Health or equivalent agency of states that mandate reporting of ECT. Information on demographics and th

Out on PubMed this week from investigators in Sweden and Norway is this study from the Swedish National Quality Register for ECT: The Effect of Pulse Width on Subjective Memory Impairment and Remission Rate 6 Months After  Electroconvulsive  Therapy. Tornhamre E, Ekman CJ, Hammar Å, Landen M, Lundberg J, Nordanskog P, Nordenskjöld A. J ECT. 2020 May 22. doi: 10.1097/YCT.0000000000000697. Online ahead of print. PMID:  32453190 The pdf is here . The study involved 312 patients with uni- or bipolar depression who received RUL ECT in 2017-18. Subjective memory was rated with the memory item from the Comprehensive Psychopathological Rating Scale (CPRS-M) before, and 6 months after, ECT. Patients were dived into 3 groups based on the pulse width ECT they received: <0.5 ms, 0.5 ms, and >0.5ms. Remission was rated using the Montgomery-Asberg Depression rating Scale-Self Assessment. The results were: "The distribution of patients with remission or a minimum of 2-step worse

Out on PubMed yesterday in JECT, from the Isle of Wight, is one of the first reports of ECT in a patient with active COVID-!9: Successful  electroconvulsive  therapy in a patient with confirmed, symptomatic covid-19. Braithwaite R, McKeown HL, Lawrence VJ, Cramer O. J ECT. 2020 May 22. doi: 10.1097/YCT.0000000000000706. Online ahead of print. PMID:  32453191   The pdf is here . Dr. Braithwaite and colleagues are to be commended for their persevereance in getting this patient the care he needed. The patient was in extremis from his psychiatric condition and catatonia, desperately needing ECT. One cannot quibble with the successful outcome, but I will comment on the variability of the technique. The authors state, "Anesthetic technique varied, according to the clinical picture and preference of the individual anesthesiologists." Induction agent and muscle relaxant doses were over a wide range, and the patient was intubated at treatments #3 and #5, but not at the 4 ot

Out on Pubmed today is this letter-to-the-editor in JECT from Okayama, Japan:  Electroconvulsive Therapy Is Effective and Safe for Serious Catatonia-Related Ileus: Two Case Reports. Yamada Y, Fujiwara M, So R, Edahiro S, Matsui Y, Sakamoto S, Kawada K, Takaki M, Ishizu S, Kanazawa K, Kishi Y, Yamada N. J ECT. 2020 May 22. doi: 10.1097/YCT.0000000000000686. Online ahead of print. PMID:  32453185 The link to the citation is above. These are 2 very well described case reports of  patients with severe medical complications in the context of catatonia. The patients received excellent medical and psychiatric care, including in one patient modifying the first 4 treatments with intubation, to reduce the risk of aspiration. The patients did well, with resolution of  both catatonia and gastrointestinal problems. This report is a reminder of the potential serious multiple medical complications that can develop with prolonged catatonia, and a call to consider ECT early in the course to

Out on PubMed yesterday is this editorial by noted ECT researcher, Harold Sackeim: The Impact of  Electroconvulsive  Therapy on Brain Grey Matter Volume: What Does It Mean? Sackeim HA. Brain Stimul. 2020 May 19:S1935-861X(20)30093-0. doi: 10.1016/j.brs.2020.04.014 . Online ahead of print. PMID:  32442625   A link to the pre-print is here . This is an erudite, theoretical piece, prompted by the neuroimaging studies of the GEMRIC collaboration. It is certainly worth reading in it's entirety, but I can summarize for you, if you prefer: we do not yet understand the pathophysiology of the observed brain structural changes seen after ECT, nor do we understand their implications for efficacy or adverse  effects. Dr. Sackeim discuses how we will need to disentangle effects from seizure, electrode placement, stimulus package and charge density in the brain, all the while taking  into account the time course of ECT's actions (sometimes very rapid). He concludes:

Today, "Classics in ECT" brings you a paper that ECT pioneer, Lothar  Kalinowsky, delivered to the New York Academy of Medicine on March 3, 1949: Present status of electric shock therapy. KALINOWSKY LB. Bull N Y Acad Med. 1949 Sep;25(9):541-53. PMID:  18138472 The pdf is here . There are many clinical "pearls" here, that still ring true today. There are also many anachronistic ideas and terms that are no longer acceptable. On the whole, however, this is a remarkable essay, worth reading in its entirety. Here are Dr. Kalinowsky's concluding words: of  The reluctance on the part of some psychiatrists to apply ECT even in those cases where a favorable result is clearly predictable, is based primarily on theoretical objections. It is true that the shock treat ments have no foundation in psychological theories; on the other hand, those thinking in organic terms, are as much at a loss to understand their action. As treating physicians we cann

Today, "Classics in ECT" features a fairly recent editorial in JAMA Psychiatry: Modern Electroconvulsive Therapy: Vastly Improved yet Greatly Underused. Sackeim HA. JAMA Psychiatry. 2017 Aug 1;74(8):779-780. doi: 10.1001/jamapsychiatry.2017.1670. PMID:  28658461   The pdf is here . From noted ECT researcher, Harold Sackeim, PhD, the editorial accompanied the below article in the same issue of JAMA Psychiatry: Slade EP, Jahn DR, Regenold WT, Case BG. Association of Electroconvulsive Therapy With Psychiatric Readmissions in US Hospitals .  JAMA Psychiatry . 2017;74(8):798‐804 The title of the editorial pretty much says it all. Dr. Sackeim reviews the state of contemporary ECT in the United States, noting that ECT is rarely used (data from the Slade et al. article: only 1.5% of general hospital inpatients with severe mood disorder receive ECT)  works much better than antidepressant medications, and has a much improved tolerability profile. He concludes: Nonclinic

Out on PubMed yesterday is this review of cognitive screening tools for ECT from neuropsychologists Donel Martin and Shawn McClintock and ECT researcher and immediate ISEN past President, Colleen Loo: Brief cognitive screening instruments for  electroconvulsive  therapy: Which one should I use? Martin DM, McClintock SM, Loo CK. Aust N Z J Psychiatry. 2020 May 21:4867420924093. doi: 10.1177/0004867420924093. Online ahead of print. PMID:  32436734 The link to the abstract is above. This is a solid review, definitely worth reading. It has 2 excellent tables, one of brief cognitive assessment tools with ECT specificity, one of general cognitive assessment tools. The authors note that the Clinical Alliance for Research in ECT (CARE) Network,  a group of over 40  sites in Australia, chose the Montreal Cognitive Assessment (MoCA) as their preferred tool. Please see also blog post of  3/29/2020 about the ECCA tool.

Today, "Classics in ECT" brings you a study in Acta Neurologica Scandinavica from 1987: A double-blind evaluation of electroconvulsive therapy in Parkinson's disease with "on-off" phenomena. Andersen K, Balldin J, Gottfries CG, Granérus AK, Modigh K, Svennerholm L, Wallin A. Acta Neurol Scand . 1987 Sep;76(3):191-9. PMID:   2446463 The pdf is here . To my knowledge, this is the only sham-controlled, blinded study of ECT in Parkinson's Disease (PD). 11 non-depressed patients with severe PD received  active or sham  (anesthesia, muscle relaxation , no stimulus)  ECT, had  comprehensive symptom ratings, and pre- and post-ECT course lumbar punctures (n=7). Real ECT resulted in significant improvement in PD symptoms for up to 6 weeks. No change in CSF neurotransmitter metabolites was found. There is a considerable literature (over 300 PubMed citations) about ECT for PD, mostly case reports or series. There is little doubt that ECT has ben

Out on PubMed this week was this study from Taiwan: Comparison of the efficacy of ECT plus  agomelatine  to ECT plus placebo in treatment-resistant depression. Lin CH, Yang WC, Chen CC, Cai WR. Acta Psychiatr Scand. 2020 May 15. doi: 10.1111/acps.13183. Online ahead of print. PMID:  32412097 The study included 97 patients and yielded completely negative results, no benefit acutely or in relapse prevention from adding agomelatine. The authors concluded: Adding agomelatine to ECT yielded comparable response/remission rates to ECT without agomelatine in the acute ECT phase. Starting agomelatine in combination with ECT did not seem to be more efficacious in preventing relapse than starting agomelatine after the acute ECT course. More research is needed to guide clinical recommendations. ECT practice has gone from prohibiting concomitant use of antidepressant medications in the old days, to now often favoring such use, with the hope of some augmentation of antidepressant effe

Today's "Classics in ECT" continues the subject from the post of 5/19/2020, ECT for schizophrenia. It is from Schizophrenia Bulletin , 1996: Convulsive therapy in schizophrenia?   Fink M ,  Sackeim HA . Schizophr Bull. 1996;22(1):27-39. doi: 10.1093/schbul/22.1.27. PMID:  8685661 The pdf is here . Drs. Fink and Sackeim conclude: "Before the advent of neuroleptic drugs, ECT was considered an effective treatment for dementia praecox. The main reason for discarding ECT was not its lack of efficacy, nor even the risks of its use, but the convenience, ease of administration, lower cost, and political and social acceptance of neuroleptic drugs. This review argues for the use of ECT early in the treatment of acutely psychotic patients, especially of first-break patients with excitement, overactivity, delusions, or florid delirium, and of young patients, to avoid the debilitating effects of chronic illness." Please see also for a recent review of the use of

Out on PubMed today is  this expert  consensus statement about treatment of schizophrenia: Clozapine Combination and Augmentation Strategies in Patients With Schizophrenia -Recommendations From an International Expert Survey Among the Treatment Response and Resistance in Psychosis (TRRIP) Working Group. Wagner E, Kane JM, Correll CU, Howes O, Siskind D, Honer WG, Lee J, Falkai P, Schneider-Axmann T, Hasan A; TRRIP Working Group. Schizophr Bull . 2020 May 18. pii: sbaa060. doi: 10.1093/schbul/sbaa060. [Epub ahead of print] The relevant ECT parts are  (from the abstract):   For clozapine-refractory positive symptoms, combination with a second antipsychotic (amisulpride and oral aripiprazole) and augmentation with  ECT  achieved consensus. For clozapine-refractory suicidality, augmentation with antidepressants or mood-stabilizers, and  ECT  met consensus criteria.  And from the text: Consensus was reached for clozapine augmentation with ECT (92.1% in the second round

Out on Pubmed recently is this study from Norway: A Longitudinal Comparison Between Depressed Patients Receiving Electroconvulsive Therapy and Healthy Controls on Specific Memory Functions. Blomberg MO, Semkovska M, Kessler U, Erchinger VJ, Oedegaard KJ, Oltedal L, Hammar Å. Prim Care Companion CNS Disord . 2020 May 14;22(3). pii: 19m02547. doi: 10.4088/PCC.19m02547. PMID:   32408397   The pdf is freely available to all on PubMed. This study involved 38 patients treated for depression with brief pulse RUL ECT at Haukeland University Hospital in Bergen, Norway. There were also 16 healthy controls. Memory functions were assessed at baseline, acutely after ECT and at 6 months. The main results were that patients scored worse on all measures of verbal and visual memory functions at baseline, and that these measures were stable for patients at each time point. Based on the AMI-SF, "patients displayed decreased autobiographical (memory) consis

"Classics in ECT" today features this review by d'Elia and Raotma from the British Journal of Psychiatry in 1975:  Br J Psychiatry. 1975 Jan;126:83-9. Is unilateral ECT less effective than bilateral ECT?  d'Elia G , Raotma H . PMID: 1092400 The pdf is here . The authors (yes, the d'Elia who originated the nearly universally used placement for RUL) review the studies up to that time comparing the efficacy of bilateral versus unilateral electrode placement. They come down strongly on the side of declaring equal efficacy between the two techniques; they also suggest that when RUL appears inferior, it is because it has not been technically optimized.  All of this, of course, preceded the studies of Harold Sackeim that further promulgated the concept of dose above seizure threshold to optimize efficacy of RUL. The debate about the relative merits of the two techniques continues to this day, and at times has unnecessarily divided the field.  My view is t

Out on PubMed recently is this statement from colleagues at Mount Sinai in New York City: A strategy for management of  ECT  patients during the COVID-19 pandemic. Bryson EO, Aloysi AS. J  ECT . 2020 May 12. doi: 10.1097/YCT.0000000000000702. [Epub ahead of print] No abstract available.  PMID:   32404699 The pdf is here . This is a very clearly presented statement of how the anesthesiologist (Dr. Bryson) and ECT practitioner  (Dr. Aloysi) worked together to modify their ECT service procedures during the COVID-19 pandemic.  It adds nicely to the recent literature giving practical suggestions to ECT providers as to how to  keep ECT services safely viable during the crisis. Not mentioned, because they do it routinely, is good  pre-oxygenation of the patients.