Clinical Neuroscience of ECT (CNECT)

In the British Journal of Psychiatry is this commentary: The pdf is here . And an excerpt from from the text: The first question must surely be motivation. Around 1.4 million people worldwide receive ECT annually.1 In psychiatric terms, ECT is relatively costly and complex, involving general anaesthesia in most countries, with estimates of annual treatment costs that ‘can exceed $10 000’. 14 If, after 80 years of ECT, there really was no evidence for effectiveness, why would healthcare providers continue funding ECT and what would psychiatrists stand to gain, especially in the face of such acrimonious criticism?  Moreover, claiming that psychiatry knowingly inflicts an invasive medical treatment with potentially serious side-effects and no evidence of substantive therapeutic benefits implies a global breach of core medical ethical principles. Not only would this violate both beneficence and nonmaleficence, but also justice, through allocating limited resources to expensive and inef...

This commentary, by Mustafa Husain and colleagues, accompanies the Carlier article in this issue of AJGP. It explores the significance of white matter hyperintensities, cognitive effects of ECT, and inflammatory markers. It nicely frames these issues and calls for more study, with the goal of making ECT more available and even better tolerated in geriatric patients. Followers of the neuroinflammation hypothesis of depression will want to read this piece, ~5 minutes.

 Out on PubMed, from clinicians in India, is this LTE: This is an interesting case report in which ECT quickly resolved longstanding mutism. No details of the ECT are given, other than treatment number and outcome. While some experts believe that antipsychotic medications are contraindicated in catatonia, the reality is that they are almost always tried in clinical situations with psychotic symptoms. Here, the authors believe they were very helpful for some symptoms; it is hard to know if they might possibly have prevented other catatonia symptoms from resolving... It is very interesting that despite being catatonic, the patient processed what was going on around him, including current events.The revelation of the delusion about his tongue is fascinating. All catatonia scholars and students will want to read this LTE in full, ~6 minutes.

 Out on PubMed, from researchers in the Lowcountries, is this study: Impact of Inflammation on Cognitive Functioning After  Electroconvulsive   Therapy in Older Patients with Depression with and Without White Matter Hyperintensities. Carlier A, Dols A, Oudega M, Sienaert P, Bouckaert F, Stek ML, Eikelenboom P, van Exel E, Rhebergen D. Am J Geriatr Psychiatry. 2021 Sep 16:S1064-7481(21)00465-6. doi: 10.1016/j.jagp.2021.09.003. Online ahead of print. PMID:  34629222   The abstract is copied below: Objective: Should we treat older, patients with depression with white matter hyperintensities (WMH) with electroconvulsive therapy (ECT)? WMH, inflammation, depression and cognitive functioning are suggested to be intertwined. Hence, this study investigates whether the association between inflammation and cognition is different in patients with depression with or without WMH. Methods: Cognitive functioning was assessed using the Mini-Mental State Examination during and a...

Out on PubMed, from investigators in Belgium, is this paper: [Electroconvulsive therapy in the treatment of depression in anorexia nervosa]. van der Lelie K, Sienaert P, Vrieze E. Tijdschr Psychiatr. 2021;63(9):673-678. PMID:  34647306   Dutch. The abstract is copied below: Background: Often anorexia nervosa occurs with other psychiatric comorbidities of which mood disorders are the most frequent. Depressive feelings hamper the chance of a favourable outcome of this persistent disorder. In addition, the underweight makes antidepressants work suboptimal. Electroconvulsive therapy (ECT) offers an important therapeutic value in the treatment of mood disorders. We are investigating whether ECT can be an effective treatment method for patients with anorexia nervosa and major depressive disorder. Aim: Analysis of the literature on the possible effectiveness of electroconvulsive therapy (ECT) in the treatment of major depressive disorder and anorexia nervosa supplemented with a case ...

  Neural Substrates of Psychotic Depression: Findings From the Global  ECT -MRI Research Collaboration. Takamiya A, Dols A, Emsell L, Abbott C, Yrondi A, Soriano Mas C, Jorgensen MB, Nordanskog P, Rhebergen D, van Exel E, Oudega ML, Bouckaert F, Vandenbulcke M, Sienaert P, Péran P, Cano M, Cardoner N, Jorgensen A, Paulson OB, Hamilton P, Kampe R, Bruin W, Bartsch H, Ousdal OT, Kessler U, van Wingen G, Oltedal L, Kishimoto T. Schizophr Bull. 2021 Oct 8:sbab122. doi: 10.1093/schbul/sbab122. Online ahead of print. PMID:  34624103 The abstract is copied below: Psychotic major depression (PMD) is hypothesized to be a distinct clinical entity from nonpsychotic major depression (NPMD). However, neurobiological evidence supporting this notion is scarce. The aim of this study is to identify gray matter volume (GMV) differences between PMD and NPMD and their longitudinal change following electroconvulsive therapy (ECT). Structural magnetic resonance imaging (MRI) data from 8 indepe...

 Out on PubMed, from investigators in Australia, is this paper: Effects of modifying the electrode placement and pulse width on cognitive side effects with unilateral  ECT : A pilot randomised controlled study with computational modelling. Martin DM, Bakir AA, Lin F, Francis-Taylor R, Alduraywish A, Bai S, Hadzi-Pavlovic D, Dokos S, Loo CK. Brain Stimul. 2021 Oct 6;14(6):1489-1497. doi: 10.1016/j.brs.2021.09.014. Online ahead of print. PMID:  34626843 The abstract is copied below: Background: The electrode placement and pulse width for electroconvulsive therapy (ECT) are important treatment parameters associated with ECT related retrograde memory side-effects. Modification of these parameters with right unilateral (RUL) ECT may have utility for further reducing these side-effects. Objective: This study explored use of the frontoparietal (FP) placement for reducing retrograde memory side effects with ECT. We hypothesised that superior retrograde memory outcomes would occur...

 Out on PubMed, from researchers at Hofstra/Northwell in New York, is this study: ECT -induced cognitive side effects are associated with hippocampal enlargement. Argyelan M, Lencz T, Kang S, Ali S, Masi PJ, Moyett E, Joanlanne A, Watson P, Sanghani S, Petrides G, Malhotra AK. Transl Psychiatry. 2021 Oct 8;11(1):516. doi: 10.1038/s41398-021-01641-y. PMID:  34625534 The abstract is copied below: Electroconvulsive therapy (ECT) is of the most effective treatments available for treatment-resistant depression, yet it is underutilized in part due to its reputation of causing cognitive side effects in a significant number of patients. Despite intensive neuroimaging research on ECT in the past two decades, the underlying neurobiological correlates of cognitive side effects remain elusive. Because the primary ECT-related cognitive deficit is memory impairment, it has been suggested that the hippocampus may play a crucial role. In the current study, we investigated 29 subjects with lon...

From the New York Times, September 21, 2021: The link to the article is: https://www.nytimes.com/2021/09/14/well/ect-therapy-depression.html And from the "Comments": ECT literally saved my Mother's life. She had stopped eating, was extremely paranoid, angry and slowly starving herself to death. I will be eternally grateful to her hospitalist who suggested that we try this treatment. While we were hesitant to prolong her suffering, the knowledge that our grandmother, her own mother had ECT more than 50 years ago and brought her back from the brink gave us the courage to try it. The results of my Mom's treatment was extraordinary--we were told it may take 5-6 treatments before she had interest in eating but after 1-2 treatments she was sending my sister out for Japanese noodles. After the completion of 12 treatments, she had totally returned to herself. She has no memory of those weeks in the hospital, which given the grave circumstances is a blessing. I am ...

Out on PubMed, from researchers in China, is this study:  Effect of modified  electroconvulsive  therapy on neuro metabolites and magnetic resonance spectroscopy imaging signals in patients with refractory obsessive-compulsive disorder. Liu D, Liang R, Bai S, Lan B, Liu G, Wang D, Yuan S, Sun W, Li G. J Affect Disord. 2021 Oct 10:S0165-0327(21)01074-0. doi: 10.1016/j.jad.2021.10.005. Online ahead of print. PMID:  34644618 The abstract is copied below: Objective: This study was aimed to investigate the effect of modified electroconvulsive therapy (MECT) on neurometabolites and magnetic resonance spectroscopy imaging (MRSI) signals in patients with refractory obsessive-compulsive disorder (OCD). Methods: From January 2018 to January 2020, 64 patients with OCD consecutively treated in the Psychiatric Department of our hospital were randomly divided into a study group treated with MECT and a control group treated with drugs alone. The obsessive-compulsive state, anxiety ...

 From investigators at the Mayo Clinic is this paper: The abstract is copied below: The pdf is here . This is a fascinating paper about thyroid augmentation of ECT and genetic variation influencing thyroid function. The study is small, the data are old (from 2008-2011) and the limitations many; nonetheless the paper rekindles the interest in T3 as an accelerator and augmenter of ECT. I have long believed that the older thyroid data from Robert Stern and colleagues were very encouraging, and that it was unfortunate that they were never adequately followed up. At the very least, this paper teaches us about thyroid metabolism and the enzymes thyroid deiodinase types I and II. I highly recommend a full read of this paper for anyone interested in the thyroid axis and depression and/or pharmacological augmentation strategies in ECT, ~ 20 minutes.

Out on PubMed, from investigators in Singapore, is this report:  Selecting right unilateral placement to facilitate continuation of electroconvulsive therapy following prolonged seizures. Goh SE, Tor PC. Asian J Psychiatr. 2021 Sep 29;66:102874. doi: 10.1016/j.ajp.2021.102874. Online ahead of print. PMID:  34624745 The abstract is copied below: Available literature remains limited in the identification of risk factors for prolonged seizures in electroconvulsive therapy and much less is reported about the continuation of electroconvulsive therapy after prolonged seizures. We describe two cases with prolonged seizures early in their course of electroconvulsive therapy and the subsequent adjustment made that allowed for safe and effective continuation of electroconvulsive therapy. In both cases, right unilateral electroconvulsive therapy was continued at a suprathreshold stimulus dose of six times relative to seizure threshold. Both patients continued their course of electroconvu...

Not on PubMed, but nonetheless in the Asian Journal of Psychiatry,  from authors in Kuwait, is this commentary: As far as I can tell, the authors wanted to publish this for the cutesy (and incomprehensible) title. While I myself have been guilty of the cutesy title, at least I always tried to back it up with substantive content. This commentary is a mishmash of "facts" and factoids about ECT and cognition, with some mechanism-of-action allusions thrown in. But we rarely get ECT publications from Kuwait, so I will give the authors some kudos for trying, and assume only the best of educational intentions.

 Out on PubMed, from authors in Romania, is this review: Efficacy of electroconvulsive therapy as a potential first-choice treatment in treatment-resistant depression (Review). Trifu S, Sevcenco A, Stănescu M, Drăgoi AM, Cristea MB. Exp Ther Med. 2021 Nov;22(5):1281. doi: 10.3892/etm.2021.10716. Epub 2021 Sep 9. PMID:  34630636 The abstract is copied below: Electroconvulsive therapy (ECT) is a technique that has been used since 1938 to treat several psychiatric disorders as a replacement for chemically induced seizures. Despite its history of stigma, controversy and low accessibility, ECT is found to be beneficial and efficient in severe cases of depression where medication fails to bring results. Titration tables developed over time, based on evidenced-based medicine, have made this treatment technique safe and, in some cases, the first choice of treatment. The aim of the review was to summarize the research conducted on the efficacy of ECT on major depressive disorder and va...

 Out on PubMed, from the Harvard group, is this paper: The Efficacy and Cognitive Effects of Acute Course Electroconvulsive Therapy Are Equal in Adolescents, Transitional Age Youth, and Young Adults. Luccarelli J, McCoy TH, Uchida M, Green A, Seiner SJ, Henry ME. J Child Adolesc Psychopharmacol. 2021 Oct 6. doi: 10.1089/cap.2021.0064. Online ahead of print. PMID:  34619038 The abstract is copied below: Objective: Electroconvulsive therapy (ECT) is the most effective acute treatment for depression, but its use in younger patients is rare and heavily regulated in many U.S. states. It is unclear whether age modifies treatment response or tolerability in adolescents, transitional age youth, and young adults. We examined the effects of ECT on depression and cognition in patients aged 16-30 years. Methods: A retrospective cohort study of patients aged 16-30 years receiving ECT between 2011 and 2020 who were evaluated with the Quick Inventory of Depressive Symptomatology (QIDS), the ...

Recently, in the New England Journal of Medicine, was this study: While this is not specifically an ECT article, it IS related. I blog about this to make the point that relapse of depression is not just an issue with ECT; it is also a major problem with antidepressants, either continued or discontinued.  The critique that ECT is merely a "short-term" treatment is ridiculous. ECT treats the current episode of mood disorder or symptom complex of other diagnoses for which it is indicated. Maintenance treatment is necessary because of the recurrent nature of the illness, not because of a shortcoming of ECT. To paraphrase a famous 1981 Lancet editorial, "It is not an ECT shortcoming that has caused the relapse, it is the illness that has done just that." (The "Quick Take Video Summary" of this article in the NEJM is 1 minute, 45 seconds.)

Today's blog post is a reminder of the dates for the ISEN Annual Meeting and ECT course next spring, both again virtual. ISEN is the largest ECT society in the world, and the annual meeting always has a top-notch scientific program. The ECT course is both for new practitioners and current practitioners looking for a comprehensive review of ECT practice. ECT nurses are also encouraged to enroll. I hope as many of you as possible will attend either, or both, thanks.