Clinical Neuroscience of ECT (CNECT)

I   will be on  hiatus  from December 24th-January 2nd, resuming on the 3rd. Please feel free to review prior blog posts, and don't forget to check PubMed.

Out on PubMed, from investigators in Japan, is this study: Two-handed facemask technique effectively causes hyperventilation in electroconvulsive therapy: an observational study. Shimamoto Y, Sanuki M, Kurita S, Ueki M, Kuwahara Y. BMC Anesthesiol. 2022 Dec 5;22(1):376. doi: 10.1186/s12871-022-01928-7. PMID:  36471246 The abstract is copied below: Background: Electroconvulsive therapy (ECT) remains the mainstay treatment option for patients with psychiatric diseases, such as severe depression. Although various anesthetic techniques provide adequate therapeutic seizures, hyperventilation is a useful adjunct to augment seizure duration and improve seizure quality. We investigated how to efficiently use a facemask to accomplish protocolized hyperventilation and evaluate its effect on ECT seizure. Methods: We studied 60 patients aged ≥18 years who underwent ECT. The patients were divided into two groups according to the technique of facemask ventilation used: the one-handed (n = 30) an...

Out on PubMed, from clinicians in Spain, is this LTE: Generalized Clonic Jerks After Administration of Etomidate Before  ECT -A Case Report. Lopez-Escribano R, Lacambra M, Asín A, Foguet-Boreu Q. J ECT. 2022 Dec 9. doi: 10.1097/YCT.0000000000000897. Online ahead of print. PMID:  36525389   The LTE is here. And here: While this is a very interesting case report, I think there may be other ways to interpret what these clinicians encountered. First off, I am skeptical about the prior super high seizure threshold (ST)- I suspect the reason the seizure was short was that the stimulus was many times OVER the ST. Furthermore, it seems paradoxical that someone with such a high ST would be hyper-irritable with etomidate. The tracings in Figure 1 might well be artifact, IMO. I wonder what would have happened if they had just continued with the ECT and assumed these were (somewhat more than) typical etomidate-induced myoclonic jerks. I would love to hear other opinions from blog fol...

Out on PubMe, from a Canadian author, is this commentary: The Rise, Fall, and Resurgence of Electroconvulsive Therapy. Bahji A . J Psychiatr Pract. 2022 Nov 1;28(6):440-444. doi: 10.1097/PRA.0000000000000666. PMID:  36355582 The abstract is copied below: Electroconvulsive therapy (ECT) is one of the most effective treatments for depression. However, significant stigma from the media and the antipsychiatry movement has biased the public toward ECT, leading to underutilization, particularly among those most in need. This report reviews some of the key historical events in the rise, fall, and resurgence of ECT and how modern ECT knowledge and practice are more refined, including an improved understanding of its mechanisms of action and optimal treatment parameters. The article is here . And from the text: This is an excellent, well-presented review/commentary on ECT. Lots of history, as well as a nice delineation the role of ECT in contemporary psychiatric medicine. One minor nit to p...

Out on PubMed, from clinicians in Belgium, in JECT, is this case report: A Case Report of Acute Cervical Dystonia After Electroconvulsive Therapy. De Moerloose S, Geerts PJ, Vanacker P, Lemmens GMD. J ECT. 2022 Dec 1;38(4):260-261. doi: 10.1097/YCT.0000000000000865. Epub 2022 May 25. PMID:  36417415 The pdf is here . The letter is here: Here's a case report of a very  rare adverse event with ECT. ECT is much more commonly beneficial for movement disorders, so this is anomalous. Note the small dose of succinylcholine (15 mg). The ECT course was continued after the event, with some improvement in the dystonia.

Out on PubMed, from investigators in Norway, is this paper: Changes in Tryptophan-Kynurenine Metabolism in Patients with Depression Undergoing  ECT - A Systematic Review. Aarsland TIM, Instanes JT, Posserud MR, Ulvik A, Kessler U, Haavik J. Pharmaceuticals (Basel). 2022 Nov 19;15(11):1439. doi: 10.3390/ph15111439. PMID:  36422569   The abstract is copied below: The kynurenine pathway of tryptophan (Trp) metabolism generates multiple biologically active metabolites (kynurenines) that have been implicated in neuropsychiatric disorders. I t has been suggested that modulation of kynurenine metabolism could be involved in the therapeutic effect of electroconvulsive therapy (ECT). We performed a systematic review with aims of summarizing changes in Trp and/or kynurenines after ECT and assessing methodological issues. The inclusion criterium was measures of Trp and/or kynurenines before and after ECT. Animal studies and studies using Trp administration or Trp depletion were excl...

"Classics in ECT" brings you this  Unmodified ECT. Crammer J. Lancet. 1980 Mar 1;1(8166):486. doi: 10.1016/s0140-6736(80)91028-4. PMID:  6102212 The pdf is here . The letter is here: Here's an articulate defense of unmodified ECT. I'm old, but not quite old enough to have done, or seen, unmodified ECT. It goes without saying that modern ECT with anesthesia is preferable, but the argument here is that unmodified ECT is not as bad as often depicted, and sometimes (much more so in 1980 than now), for some patients might be (have been) justifiable, based on the benefit-risk calculation. Not to be discussed outside of our professional circles, but certainly something for the field to know about from the older literature, including this LTE. (Please see also recent blog post about the author, John Crammer.)

"Classics in ECT" bring you this case series from 1988, from clinicians in Vancouver, Canada: Treatment of dopaminomimetic psychosis in Parkinson's disease with  electroconvulsive  therapy. Hurwitz TA, Calne DB, Waterman K. Can J Neurol Sci. 1988 Feb;15(1):32-4. doi: 10.1017/s0317167100027141. PMID:  3345460 The abstract is copied below: Two Parkinsonian patients with chronic nonconfusional dopaminomimetic psychosis were treated with a course of electroconvulsive therapy. In both cases sustained remission of psychosis was obtained in the face of ongoing administration of dopaminomimetics. The article is here . And here: Here's a classic well-presented report of two cases of dopaminergic psychosis in patients with PD, successfully treated with short courses of ECT. I do like the sentence about choosing between "mobile and mad" or "sane but unable to move" with pharmacotherapy. I blog about this because it is good to know about another citation in th...

Out on PubMed, from authors in China, is this study: Electroconvulsive therapy for obsessive-compulsive disorder: A retrospective study. Li K, Long J, Deng W, Cheng B, Wang J. Front Psychiatry. 2022 Nov 9;13:1040443. doi: 10.3389/fpsyt.2022.1040443. eCollection 2022. PMID:  36440390 The abstract is copied below: Background: Chronic mental diseases such as obsessive-compulsive disorder (OCD) are associated with a high disability rate. Some patients still do not improve their symptoms even with adequate cognitive-behavioral therapy and drug treatment. In the treatment of OCD, electroconvulsive therapy (ECT) is not considered a neuromodulation modality with sufficient evidence. Objective: This retrospective study aimed to determine the efficacy and associated risk factors of ECT in OCD patients. Materials and methods: The study included 21 OCD patients who underwent ECT at a high-volume center in China between January 2009 and December 2020 . The demographics and clinical characterist...

Out on PubMed, from an international array of authors, is this case report: Recurrent Catatonia due to Episodic Obsessive-Compulsive Disorder. Das S, Prasad S, Fichadia PA, Shrestha AB, Amuk Williams OC, Bachu A. Case Rep Psychiatry. 2022 Nov 15;2022:2022474. doi: 10.1155/2022/2022474. eCollection 2022. PMID:  36425076 The pdf is here . I tried to like this case report; after all, the possible relation between OCD and catatonia is interesting. Unfortunately, this case report (not the patient) is a hot mess. About the only thing to hang your hat on is that the patient's catatonic symptoms remitted quickly with ECT. And there's this: Huh? Well, the first sentence of that paragraph seems ok. And what about the random presentation of two pieces of ECT data (initial seizure threshold, seizure duration) as the total description of the ECT course? Kudos to the authors for getting the patient well with ECT, but only partial kudos for this contribution to the literature...

Out on PubMed, from clinicians in India, is this case report: Treatment of Ekbom Syndrome With Clozapine and Electroconvulsive Therapy. Singh A, Shah R, Cholera R, Mulky P. Cureus. 2022 Oct 19;14(10):e30469. doi: 10.7759/cureus.30469. eCollection 2022 Oct. PMID:  36415401   The abstract is copied below: Delusion of parasitosis (DP), which is also known as Ekbom syndrome, is a delusional disorder characterised by a false, fixed belief of being infested by insects or mites, despite the lack of supporting medical evidence. This disorder presents most commonly with the "Matchbox sign." DP can present as a primary or secondary delusional disorder. It can be associated with various psychiatric conditions such as schizophrenia spectrum disorders, mood disorders, anxiety or substance abuse. Several organic conditions such as dementia, malignancies, vitamin deficiencies and cerebrovascular accidents can mimic symptoms of DP. Hereby, we present a case of schizophrenia in a young woman...

 Out on PubMed, from researchers in France, is this study: Peripheral proteomic changes after electroconvulsive seizures in a rodent model of non-response to chronic fluoxetine. Lebeau RH, Mendez-David I, Kucynski-Noyau L, Henry C, Attali D, Plaze M, Colle R, Corruble E, Gardier AM, Gaillard R, Guilloux JP, David DJ. Front Pharmacol. 2022 Oct 31;13:993449. doi: 10.3389/fphar.2022.993449. eCollection 2022. PMID:  36386166 The abstract is copied below: Major depressive disorder (MDD) is the psychiatric disorder with the highest prevalence in the world. Pharmacological antidepressant treatment (AD), such as selective serotonin reuptake inhibitors [SSRI, i.e., fluoxetine (Flx)] is the first line of treatment for MDD. Despite its efficacy, lack of AD response occurs in numerous patients characterizing Difficult-to-treat Depression. ElectroConvulsive Therapy (ECT) is a highly effective treatment inducing rapid improvement in depressive symptoms and high remission rates of ∼50-63% in...

Out on PubMed, from clinicians in India, is this article: Maintenance electroconvulsive therapy: Are we clutching at straws? Christina M, Chichra A, Kattula D, Innamuri R, Akula V. J Family Med Prim Care. 2022 Jul;11(7):4088-4093. doi: 10.4103/jfmpc.jfmpc_2389_21. Epub 2022 Jul 22. PMID:  36387666 The abstract is copied below: Introduction: The available treatment options for patients with drug or treatment-resistant psychiatric disorders are limited. Maintenance electroconvulsive therapy (M-ECT) is an established option, but the literature available is limited. This study examined the utilization of M-ECT in a large tertiary care psychiatric facility, and its correlates with the socio-demographic and clinical profile of patients. Methods: A retrospective chart review was performed in a tertiary care psychiatry center based in semi-urban South India, and data was analyzed. Results: A total of 171 patients received ECT in the study period, of which only five patients were on M-ECT. ...

"Classics in ECT" brings you this brief communication from the American Journal of Psychiatry, 1971: ECT in LSD psychosis. a report of three cases. Muller DJ. Am J Psychiatry. 1971 Sep;128(3):351-2. doi: 10.1176/ajp.128.3.351. PMID:  5106263   The pdf is here . And the article is here: This is a fun one, and potentially of relevance today, as hallucinogenic drugs make a comeback. Short courses of RUL ECT with dramatic results! There are similar case reports/series of ECT for PCP psychosis.

Lithium for manic depressive disorders, challenge to electroshock therapy? Fieve RR. N Y State J Med. 1971 Sep 15;71(8):2219-22. PMID:  5284488 The full NY Times obituary is at this link: https://www.nytimes.com/2018/01/12/obituaries/dr-ronald-fieve-87-dies-pioneered-lithium-to-treat-mood-swings.html I  blog about this little historical tidbit to note one of many examples of the premature touting of the replacement of ECT by medications, and to remind us of one of the great pioneers of lithium therapy. I note also the use of "electroshock" and "ecs" rather than ECT, in 1971. With apologies for not having the full manuscript; if anyone can access it and post, I would be grateful.