PURPOSE OF REVIEWECT remains an important, yet underutilized, treatment for schizophrenia. Recent research shows that medication-resistant patients with schizophrenia, including those resistant to ...clozapine, respond well to ECT augmentation. The purpose of this article is to review recent studies of the use of ECT in the treatment of schizophrenia.
RECENT FINDINGSWe performed an electronic database search for articles on ECT and schizophrenia, published in 2017. The main themes of these articles areepidemiological data on ECT use from various countries; retrospective studies, prospective studies and meta-analyses focusing on efficacy and cognitive side-effects of ECT in schizophrenia; ECT technical parameters and potential biomarkers.
SUMMARYThere is growing evidence to support the use of ECT for augmentation of antipsychotic response in the treatment of schizophrenia. Cognitive side-effects are generally mild and transient. In fact, many studies show improvement in cognition, possibly related to the improvement in symptoms. There is wide variation among countries in the use of ECT for the treatment of schizophrenia. There are also variations in the choice of ECT electrode placement, parameters and schedules. These technical differences are likely minor and should not interfere with the treatment being offered to patients. Further, long-term studies are needed to optimize ECT treatment parameters, to examine the effect of maintenance ECT and to investigate neuroimaging/biomarkers to understand the mechanism of action and identify potential response predictors to ECT.
Objective:Up to 70% of patients with treatment-resistant schizophrenia do not respond to clozapine. Pharmacological augmentation to clozapine has been studied with unimpressive results. The authors ...examined the use of ECT as an augmentation to clozapine for treatment-refractory schizophrenia.Method:In a randomized single-blind 8-week study, patients with clozapine-resistant schizophrenia were assigned to treatment as usual (clozapine group) or a course of bilateral ECT plus clozapine (ECT plus clozapine group). Nonresponders from the clozapine group received an 8-week open trial of ECT (crossover phase). ECT was performed three times per week for the first 4 weeks and twice weekly for the last 4 weeks. Clozapine dosages remained constant. Response was defined as ≥40% reduction in symptoms based on the psychotic symptom subscale of the Brief Psychiatric Rating Scale, a Clinical Global Impressions (CGI)-severity rating <3, and a CGI-improvement rating ≤2.Results:The intent-to-treat sample included 39 participants (ECT plus clozapine group, N=20; clozapine group, N=19). All 19 patients from the clozapine group received ECT in the crossover phase. Fifty percent of the ECT plus clozapine patients met the response criterion. None of the patients in the clozapine group met the criterion. In the crossover phase, response was 47%. There were no discernible differences between groups on global cognition. Two patients required the postponement of an ECT session because of mild confusion.Conclusions:The augmentation of clozapine with ECT is a safe and effective treatment option. Further research is required to determine the persistence of the improvement and the potential need for maintenance treatments.
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 longitudinal MRI and detailed neuropsychological testing in two independent cohorts (N = 15/14) to test if volume changes were associated with cognitive side effects. The two cohorts underwent somewhat different ECT study protocols reflected in electrode placements and the number of treatments. We used longitudinal freesurfer algorithms (6.0) to obtain a bias-free estimate of volume changes in the hippocampus and tested its relationship with neurocognitive score changes. As an exploratory analysis and to evaluate how specific the effects were to the hippocampus, we also calculated this relationship in 41 other areas. In addition, we also analyzed cognitive data from a group of healthy volunteers (N = 29) to assess practice effects. Our results supported the hypothesis that hippocampus enlargement was associated with worse cognitive outcomes, and this result was generalizable across two independent cohorts with different diagnoses, different electrode placements, and a different number of ECT sessions. We found, in both cohorts, that treatment robustly increased the volume size of the hippocampus (Cohort 1: t = 5.07, Cohort 2: t = 4.82; p < 0.001), and the volume increase correlated with the neurocognitive T-score change. (Cohort 1: r = -0.68, p = 0.005; Cohort 2: r = -0.58; p = 0.04). Overall, our research indicates that novel treatment methods serving to avoid hippocampal volume increase may result in a better side effect profile.
The ubiquitous coronavirus 2019 (COVID-19) pandemic has required healthcare providers across all disciplines to rapidly adapt to public health guidelines to reduce risk while maintaining quality of ...care. Electroconvulsive therapy (ECT), which involves an aerosol-generating procedure from manual ventilation with a bag mask valve while under anesthesia, has undergone drastic practice changes in order to minimize disruption of treatment in the midst of COVID-19. In this paper, we provide a consensus statement on the clinical practice changes in ECT specific to older adults based on expert group discussions of ECT practitioners across the country and a systematic review of the literature. There is a universal consensus that ECT is an essential treatment of severe mental illness. In addition, there is a clear consensus on what modifications are imperative to ensure continued delivery of ECT in a manner that is safe for patients and staff, while maintaining the viability of ECT services. Approaches to modifications in ECT to address infection control, altered ECT procedures, and adjusting ECT operations are almost uniform across the globe. With modified ECT procedures, it is possible to continue to meet the needs of older patients while mitigating risk of transmission to this vulnerable population.
Early studies reported a prolactin surge during electroconvulsive therapy (ECT). The aim of this study is to review and meta-analyze data on ECT-related prolactin changes.
A systematic review and ...meta-analysis was conducted for trials investigating prolactin changes in ECT-treated patients using standard mean differences (SMD, 95% confidence intervals). Subgroup analyses included comparisons of ECT-related prolactin changes in women vs. men, patients receiving different anesthetics, bilateral vs. unilateral and high-vs. low-dose ECT.
In six trials including 109 ECT-treated patients and 74 controls, prolactin changes were larger in ECT-treated patients than in controls (SMD = 0.89, 95%CI = 0.55, 1.23, p < 0.001 and 1.03, 95%CI = 0.31, 1.75, p = 0.005 for the fixed and random-effect model respectively), despite heterogeneity in the samples (I2 = 72%, τ2 = 0.62). Effects were led by differences in patients premedicated with methohexital (SMD = 1.14, 95%CI = 0.7, 1.57, p < 0.001 for both fixed and random-effect model). A meta-regression reported significant age effects (coefficient estimate 2.32, 95%CI = −0.73, 3.91, p < 0.01). Additionally, prolactin changes were larger in ECT-treated women than men (SMD = 0.88, 95%CI = 0.58, 1.18, p < 0.001 and 0.99, 95%CI = 0.22, 1.75, p = 0.012 for the fixed and random effect model). Bilateral ECT-treated patients had larger increase than unilateral ECT-treated patients (SMD = −0.81, 95%CI = −1.35, −0.27, p = 0.003 and −0.86, 95%CI = −1.46, −0.25, p = 0.006 for the fixed and random-effect model). Comparisons between high- and low-dose ECT-treated patients could not be conducted. The quality of the studies was overall poor, with four exceptions.
Patients receiving ECT had larger prolactin increases than controls. Increases were larger in methohexital-premedicated patients, women vs. men and patients with bilateral vs. unilateral ECT.
•ECT-treated patients showed larger prolactin increase compared to controls.•The prolactin increase was considerably larger in ECT-treated women compared to men.•Prolactin increase was larger in bilateral vs. unilateral ECT-treated patients.
New-onset refractory status epilepticus (NORSE) describes prolonged or recurring new onset seizures which fail to respond to antiseizure medications. NORSE poses a challenge in diagnosis and ...treatment, and limited high-quality evidence exists to guide management. The efficacy of Electroconvulsive therapy (ECT) in aborting refractory status epilepticus has been described in case reports, but its application remains uncommon, particularly in young children. We describe a case of NORSE in a 3-year old child in which ECT played an important role in aborting status epilepticus, facilitating the diagnosis and surgical excision of an underlying focal cortical dysplasia. Although further research is needed, our case suggests that ECT can be a valuable tool in the treatment of refractory status epilepticus in children.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Recent longitudinal neuroimaging studies in patients with electroconvulsive therapy (ECT) suggest local effects of electric stimulation (lateralized) occur in tandem with global seizure activity ...(generalized). We used electric field (EF) modeling in 151 ECT treated patients with depression to determine the regional relationships between EF, unbiased longitudinal volume change, and antidepressant response across 85 brain regions. The majority of regional volumes increased significantly, and volumetric changes correlated with regional electric field (t = 3.77, df = 83, r = 0.38, p=0.0003). After controlling for nuisance variables (age, treatment number, and study site), we identified two regions (left amygdala and left hippocampus) with a strong relationship between EF and volume change (FDR corrected p<0.01). However, neither structural volume changes nor electric field was associated with antidepressant response. In summary, we showed that high electrical fields are strongly associated with robust volume changes in a dose-dependent fashion.
Although aggressive behavior in psychiatric settings is a major concern, very few studies have focused exclusively on physical assault in a general inpatient psychiatric population.
This study had 3 ...main goals: (1) to evaluate the prevalence of assaultive behavior in an acute psychiatric hospital; (2) to identify the clinical and socio-demographic factors associated with assaultive behavior during hospitalization; and (3) to explore whether a diagnosis of schizophrenia spectrum disorder increases the risk of assaultive behavior.
We conducted a retrospective chart review of patients admitted to acute units in a psychiatric hospital between 2009 and 2012. A subset of occurrence reports identified by a multidisciplinary team as "physical assault" was included in the analysis. Using logistic multivariate regression analysis, these patients were compared with a randomly selected nonassaultive control group, matched for length of stay to identify factors associated with assaultive behavior.
Of 757 occurrence reports, 613 met criteria for significant assault committed by 356 patients over 309,552 patient days. The assault incident density was 1.98 per 1000 patient days. In the logistic regression model of best fit, the factors significantly associated with assaultive behavior were age, legal status, and substance use. A diagnosis of schizophrenia spectrum disorder was not significantly associated with assaultive behavior.
Clinicians should take extra precautions for involuntarily admitted young patients with a history of substance use, as they are more likely to exhibit assaultive behavior. A diagnosis of schizophrenia spectrum disorder in itself is not significantly associated with assaultive behavior. Screening instruments such as the Dynamic Appraisal of Situational Aggression may be useful in assessing risk of assault.
Anti-NMDA receptor encephalitis frequently presents with a wide range of psychiatric and behavioral symptoms such as catatonia and psychosis. Although immunomodulatory therapy, together with the ...teratoma removal whenever present, is the mainstay treatment, additional treatments are often needed to mitigate the psychosis and catatonia. However, antipsychotics are often either ineffective or poorly tolerated. We present a single-health system retroactive case series of the use of electroconvulsive therapy (ECT) in catatonic syndrome of definitive, probable, or possible immune origin.
To determine the efficacy and safety of ECT for the management of catatonic syndrome associated with anti-NMDAR encephalitis and new-onset psychoses of suspected immune origin using consensus criteria described by Pollak et al in 2020.
A retrospective medical records review on the demographic data, clinical characteristics, relevant laboratory findings, immunomodulatory therapies administered, and clinical outcomes of all the patients treated with ECT at our health system from Jan 2017 to Dec 2022 for the catatonic syndrome associated with anti-NMDR encephalitis or new-onset psychosis of either possible or probable immune origin. Clinical assessment of catatonic symptoms using the Bush Francis Catatonia Rating Scale (BFCRS) before and after ECT treatments as well as the time interval from the estimated onset of illness to first ECT treatment were reviewed and reported.
There were 12 cases of ECT used as an adjuvant therapy to manage persistent catatonic syndrome, despite treatment with various immunotherapies, associated with either anti-NMDAR encephalitis (n=4), or new-onset psychosis of possible (n=2) or probable (n=6) immune origin. Patients were often young (mean age 26 years) with slight female predominance (58%). Mean initial BFCRS score was 18.2 (range: 5-25). All patients responded well to the combination of immunotherapies and ECT, and showed some response after 3 ECT treatments. Complete resolution of catatonia was achieved in 11 patients (92%). Patients required an average of 11 ECT treatments (range: 3-21) to achieve maximum improvement.
This is the largest single-health system retrospective case series showing ECT modality to be highly effective and safe adjuvant therapy for all forms of catatonic syndrome of confirmed or suspected immune origin, including those refractory to the standard treatment combined with immunotherapies. Our report underscores the importance of high index of clinical suspicion in early recognition of the immune-mediated catatonic syndrome, particularly among those with a prior history of psychiatric illnesses. This is important to prevent catatonia-related medical complications. It also provides additional support for early and consistent use of ECT modality in the management of immune-mediated catatonia in association with anti-NMDAR encephalitis and other suspected central nervous system autoimmunity. Large-scale randomized clinical studies might provide pivotal insights sufficient for incorporating ECT modality into the treatment algorithm for catatonic syndrome associated with autoimmunity.
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