Factors Associated With Postictal Agitation After Electroconvulsive Therapy.

OBJECTIVE: This study investigated the occurrence of postictal agitation (PA) in patients undergoing an acute series of electroconvulsive therapy (ECT) and further explored patient and treatment variables associated with PA. METHODS: Charts were retrospectively searched for patients undergoing an acute series of ECT. Postictal agitation was identified by the administration of a sedative after ECT. Demographic, diagnostic, medication, and ECT variables that could also be associated with PA were collected and accounted for in statistical analysis. RESULTS: In this population, 22 of 156 patients experienced PA. Associations that reached statistical significance included sex, weight, active substance use disorder, seizure duration (as observed by motor movements), and waking time. Only seizure duration and waking time maintained significance after multivariable analysis. CONCLUSIONS: These data identify clinical factors that could help predict PA. Patients with greater weight, male sex, or an active substance use disorder ought to be carefully monitored for PA, and staff in the recovery suite should be especially vigilant about such patients with longer seizures and waking times.

Effectiveness of Electroconvulsive Therapy in Patients With Major Depressive Disorder and Comorbid Borderline Personality Disorder.

OBJECTIVE: Previous research suggests that electroconvulsive therapy (ECT)-the criterion standard for the treatment of severe depression-is not as effective when the patient has comorbid borderline personality disorder (BPD). The ECT outcomes of patients with and without BPD were compared in a retrospective chart review to test this claim. METHODS: We enrolled 137 patients with a diagnosis of major depressive disorder who completed the McLean Screening Instrument for Borderline Personality Disorder. Twenty-nine patients had positive screening scores for BPD. The difference in Patient Health Questionnaire (PHQ-9) scores before and after ECT was compared between patients with and without BPD. Follow-up PHQ-9 scores determined after treatment were collected and analyzed. RESULTS: Electroconvulsive therapy equally improved symptoms of depression as measured by PHQ-9 score in both patients who screened positive and patients who screened negative for BPD. No difference in the increase in PHQ-9 scores between these 2 groups was noted 1 month after treatment (P = 0.19). CONCLUSIONS: These data showed that a positive BPD screen does not necessarily predict a poorer response to ECT, nor does it predict greater symptom recurrence after ECT. This does not suggest that ECT is necessarily an appropriate treatment for major depressive disorder in patients with a comorbid BPD, given the limitations of screening instruments.

The PRIDE Study and the Conduct of Electroconvulsive Therapy: Questions Answered and Unanswered.

The recently published PRIDE study (prolonging remission in the depressed elderly) constitutes an important contribution to electroconvulsive therapy (ECT) technique, from the standpoint of both the index course to treat depressive symptoms and the post-remission continuation period to prevent relapse. This study was probably the last large, National Institute of Mental Health-funded, multisite ECT technical study for some time to come, so extracting clinically relevant recommendations is worthwhile. In this commentary, the author discusses evidence from this trial relevant to several important clinical index and continuation ECT technical issues and elaborates several unanswered questions deserving further consideration.

Mirtazapine for Symptomatic Relief on a Psychiatric Consultation Service: A Case Series.

BACKGROUND: With a complex pharmacologic profile, mirtazapine may promote sleep, stimulate appetite, improve nausea, and reduce pain. Some practitioners working on the Mayo Clinic inpatient psychiatric consultation/liaison service have recommended mirtazapine in medically ill patients with or without formal psychiatric comorbidity to target these symptoms. OBJECTIVE: To assess the success of this practice, we conducted a retrospective chart review covering a 4.5-year period. METHODS: For patients recommended to start mirtazapine, global improvement in specific symptoms and suspected side effects were recorded. RESULTS: During the study period, 528 medically ill patients started mirtazapine following a recommendation from the psychiatric consultation service. In total, 475 patients were provided mirtazapine to specifically target sleep, nausea, pain, or appetite. There was documented improvement in these symptoms for 37.7%, 37.0%, 36.4%, and 23.5% of the patients, respectively. These rates of improvement are conservative for the 229 patients without documented response, i.e., 48% of the patients who were given the medication for a somatic symptom were counted as having no improvement. Commonly documented adverse effects were daytime sedation (5.3%), worsening mental status (2.3%), and nightmares (1%). CONCLUSIONS: Despite the limitations of this retrospective, qualitative study, these data confirm that mirtazapine is generally well tolerated and can provide at least short-term relief of certain symptoms in medically ill patients. Controlled trials are needed to assess these benefits more systematically, and it is not clear how long mirtazapine should be used for these symptoms.

What Type of Cognitive Testing Should Be Part of Routine Electroconvulsive Therapy Practice?

Several decades of research have yielded much information on the cognitive effects of electroconvulsive therapy (ECT) and have informed ECT technical factors such as electrode placement, stimulus dosing, and stimulus parameters. However, the question of what type of cognitive testing should be part of routine ECT practice has not been definitively clarified. The author reviews the recommendations, or lack thereof, in several published ECT guidelines and discusses the purposes that cognitive testing during ECT should serve and difficulties that most ECT services would encounter with intensive testing schedules. Practical utility of formal cognitive testing during and after ECT has not been satisfactorily demonstrated in ECT research. In addition, several key aspects of testing, such as cognitive domain to be tested, specific tests to be used, personnel to do the testing, time points of testing, and exactly how the test results will be interpreted and used have yet to be determined with precision. It is suggested that research efforts be undertaken to address these large gaps in ECT practice.

Clinical Challenges in Maintenance Electroconvulsive Therapy for Older Patients With Medical Comorbidity.

As patients receiving maintenance electroconvulsive therapy (MECT) age, many will acquire medical illnesses that may complicate their course of ECT and the treatment of their underlying psychiatric conditions. In this study, we present 7 cases of patients receiving MECT whose medical illnesses resulted in clinical reassessment of whether or not MECT should be continued. We discuss clinical implications and considerations for treating medically ill patients with MECT.

An Open-Label, Pilot Study of Daily Right Unilateral Ultrabrief Pulse Electroconvulsive Therapy.

Right unilateral ultrabrief (RUL-UB) pulse width electroconvulsive therapy (ECT) has attracted much research attention recently due to its smaller effect on memory than is associated with other forms of ECT, such as bitemporal placement or unilateral standard pulse width. However, RUL-UB has demonstrated slower antidepressant efficacy in comparison to the other techniques. One method to enhance the speed of response to RUL-UB ECT is administration of 5 times a week (termed "daily") treatments as opposed to the more standard twice or thrice weekly schedule. In this open label study, we treated 20 depressed patients with daily RUL-UB treatments for up to 2 weeks (ie, 10 treatments) using standardized assessments of depression and retrograde amnesia. Response and remission rates were commensurate with those reported in other recent studies using this technique with twice or thrice weekly treatment frequencies, and there was no clinically significant effect on retrograde memory function. We conclude that daily administration of RUL-UB ECT may shorten the duration of the course of ECT treatments without compromising cognition. A randomized trial comparing this technique to a thrice weekly schedule of RUL-UB treatments is indicated.

Thiothixene in the Management of Delirium: A Case Series.

BACKGROUND: Pharmacologic strategies are often required to help manage agitated patients with delirium. First-and second-generation antipsychotic medications (such as haloperidol, quetiapine, and olanzapine) are commonly used. OBJECTIVE: On the psychiatric consultation service in our hospital, thiothixene has been used based on its favorable potency, sedative, and cost profiles. Little has been written about the utility of this drug for management of delirium. METHODS: We reviewed our experience with thiothixene in this setting using pharmacy records to identify patients who received at least 1 dose between July 2011 and March 2014. We scrutinized the relevant medical records (n = 111) and recorded the following data: age, sex, medical diagnoses, signs and symptoms of delirium, dosing of thiothixene, and response to thiothixene in terms of both apparent benefit as well as side effects. RESULTS: Resolution or improvement was documented in 78% of patients and good tolerability in 82% of patients. CONCLUSIONS: Although further data from a randomized, controlled trial would be ideal, our experience suggests that thiothixene could be a safe and effective pharmacologic treatment for agitation and psychosis due to delirium.

Do patients with personality disorders respond differentially to electroconvulsive therapy? A review of the literature and consideration of conceptual issues.

Personality disorders are common among depressed patients. While there is considerable research demonstrating that such patients may respond less optimally to antidepressant medications, there is a relative dearth of research on the outcomes of depressed personality-disordered patients treated with electroconvulsive therapy (ECT). In this review, the author summarizes the available reports and concludes that there is reasonably robust evidence that patients with borderline personality disorder experience lesser antidepressant responses to ECT acutely and probably higher post-ECT relapse rates than depressed patients with other or no personality disorders. Some of the complex issues involved in selecting and treating such patients are discussed, and recommendations are provided for clinical practice and future research.

Lithium for post-electroconvulsive therapy depressive relapse prevention: a consideration of the evidence.

Lithium has been used for several decades as a prophylactic against depressive relapse after successful index electroconvulsive therapy (ECT). The literature on this topic is reviewed, and it is concluded that, in the main, there is strong evidence that lithium can help prevent relapses in the first 6 months after index ECT. However, there are several unanswered questions about its use post-ECT, including optimal target blood level, duration of use, and concomitant antidepressant choice. In this report, the author provides a review of the evidence for using lithium in this setting, outlines the pertinent unanswered questions, and proposes future research directions and guidelines for current clinical care.

Court-Approved Electroconvulsive Therapy in Patients Unable to Provide Their Own Consent: A Case Series.

For patients who lack capacity to consent to electroconvulsive therapy (ECT) for various reasons (intellectual disability, severe mental illness, dementia, etc), court approval must be obtained to proceed with the treatments. We reviewed our experiences on a busy tertiary center ECT service in which we have treated 24 patients in recent years under the auspices of court approval for consent. We found that these patients generally tolerated the treatments well and had noticeable improvement in their symptoms as well as overall better quality of life. In particular, although the patients were unable to provide their own consent for ECT, they were amenable to receive the treatments and did not seem resistant or hostile to the treatment process. We conclude that, in patients unable to provide their own consent, court-approved ECT is well tolerated.

Propofol for ECT anesthesia a review of the literature.

Propofol is a commonly used anesthetic drug for electroconvulsive therapy (ECT), as evidenced by the frequency with which its use is reported in ECT literature. Concerns have been raised over its propensity to be associated with shortened seizure duration vis-à-vis other anesthetic drugs, thus limiting its use in some settings. However, in the surgical anesthesia literature, propofol has shown distinct advantages such as improved hemodynamics and postanesthesia recovery. Given the capricious availability of standard barbiturate anesthetics in some countries, propofol use has probably increased. Thus, a review of its profile for a number of outcome measures in ECT is appropriate. Herein, the author reviews the extensive literature for propofol in ECT, focusing on 5 outcome measures: seizure duration, hemodynamics, postanesthesia recovery, cognitive adverse effects, and therapeutic efficacy. Results indicate that propofol is indeed robustly associated with shorter seizures than other anesthetics but that antidepressant efficacy does not seem to be compromised. Heart rate and blood pressure changes are not as high with propofol, and postanesthesia recovery may be quicker with propofol as well. Not enough data are available regarding cognitive adverse effects to make definitive conclusions, but so far, there does not seem to be a worsened cognitive profile when it is used in ECT. Propofol seems to be an acceptable anesthetic for ECT with advantages for some situations. Using the lowest effective anesthetic dosage minimizes its effect on seizure elicitation and duration.

Some considerations of the tolerability of ketamine for ECT anesthesia: a case series and review of the literature.

Most anesthetic agents used for electroconvulsive therapy (ECT) have few intrinsic adverse effects. Ketamine, however, is well known to be associated with a variety of adverse effects including nausea, dizziness, and psychotomimetic phenomena. Over the past several decades, there have been numerous reports on the use of ketamine for ECT anesthesia, with varied assessments on how prominent these adverse effects are in the ECT situation. Ketamine has received a resurgence of interest as an ECT anesthetic of late owing to its established independent antidepressant effects and to theoretical reasons why it might lessen the cognitive adverse effects of ECT. In this case series, the author reviews the experience with 14 patients who had undergone ECT who were switched to ketamine as anesthetic from methohexital at the preference of the treating anesthesiologist. All 14 patients spontaneously reported a strong preference not to be given ketamine again due to bothersome adverse effects. The latter consisted of either vestibular-type symptoms (nausea/vomiting, dizziness, and vertigo) or psychotomimetic effects (dissociative phenomena). It is concluded that ketamine is not free of adverse effects when used as an ECT anesthetic. Electroconvulsive therapy clinicians should be vigilant about assessing for these effects when ketamine is used, and consideration should be given to using a benzodiazepine such as diazepam or midazolam at seizure termination when ketamine anesthesia is used to prevent bothersome adverse effects seen upon awakening.

Anesthetic-induced pain on injection in electroconvulsive therapy: review of the literature and suggestions for prevention.

Pain on injection (angialgia) is a common adverse effect of anesthetic medications, especially propofol and methohexital, which are both used for electroconvulsive therapy (ECT). In this review, the authors survey some general literature on angialgia incidence, mechanisms, and prevention efforts in non-ECT settings and follow this with a review of similar topics relevant to ECT. They review practical methods of angialgia prevention for ECT patients. The methods with the best research basis include the use of an antecubital vein for intravenous access as well as the local anesthetic lidocaine. Regarding the latter, concerns regarding shortening of seizure duration during ECT have been raised. If lidocaine is used for angialgia in ECT, low doses should be administered to avoid possible interference with ictal electroencephalogram expression. Other methods worth studying further for angialgia during ECT include use of the antiemetic agent metoclopramide and high-potency opiates.

Psychiatric side effects of ketamine in hospitalized medical patients administered subanesthetic doses for pain control.

OBJECTIVE: To assess the psychiatric side effects of ketamine when administered in subanesthetic doses to hospitalized patients. It is hypothesized that such effects occur frequently. METHODS: In this retrospective study, the medical records of 50 patients hospitalized on medical and surgical units at our facility who had continuous intravenous infusions of ketamine for pain or mild sedation were reviewed. Patient progress in the days following the start of ketamine infusion was reviewed and response to ketamine was noted. RESULTS: Twenty-two percent of the patients were noted to have some type of psychiatric reaction to ketamine, including agitation, confusion, and hallucinations. These reactions were relatively short lived, namely, occurring during or shortly after the infusions. No association was found between patient response to ketamine and gender, age, or infusion rate. CONCLUSION: Awareness of the psychiatric side effects of ketamine is an important consideration for clinicians administering this medication either for pain control or for depressive illness.

Methohexital-induced seizures during electroconvulsive therapy.

Methohexital is a common anesthetic agent used for electroconvulsive therapy. In the adult literature, there are a few case reports of tonic-clonic seizures occurring immediately after the administration of methohexital. However, to date, there are no reports of this occurrence in children or adolescents. This case documents a generalized tonic-clonic seizure in a 15-year-old girl after receiving 60 mg of methohexital and numerous prior episodes of bitemporal electroconvulsive therapy.

Electroconvulsive therapy and melancholia: review of the literature and suggestions for further study.

It has long been lore in the electroconvulsive therapy (ECT) field that melancholic depression is particularly responsive to ECT, whereas nonmelancholic depressions are less so. Early large case series in the 1940s and 1950s, while using now outdated diagnostic nosologies, did provide some hints to the particular efficacy of what later on would be considered melancholic or endogenous depression. The first systematic studies of this subject in the 1950s and 1960s seemed to confirm the superior response of endogenous depression to ECT. However, with the advent of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, and the first criterion set specifically labeled "melancholia," most modern series of studies have failed to find an association of melancholic symptoms with ECT response. Several problems both with the definition of melancholia and the modern methods of diagnosis and outcome assessment are hypothesized to be at the root of the negative findings of modern studies. Suggestions for future ECT/melancholia studies are offered.

Some considerations in choosing electroconvulsive therapy versus transcranial magnetic stimulation for depression.

Transcranial magnetic stimulation (TMS) has recently been approved by the Food and Drug Administration for treatment of depression refractory to at least 1 antidepressant medication. Clinical psychiatrists as well as patients are likely to inquire about TMS as a therapeutic option for the depressed patient. In particular, as TMS is a procedure that has at least some superficial similarities to electroconvulsive therapy (ECT), there will be interest in using TMS as a possible alternative to ECT. On the other hand, ECT has been in use for many decades and has a well-established track record of being the most effective treatment for depression. In this article, the author reviews the efficacy, adverse effect profile, cost, and inconvenience issues for both TMS and ECT and outlines some considerations for current clinical decision making regarding the choice between these 2 modalities.

The safety of electroconvulsive therapy in patients with prolonged QTc intervals on the electrocardiogram.

BACKGROUND: Prolonged QTc intervals have been associated with increased cardiac morbidity and mortality. We investigated whether pretreatment prolongation of the QTc interval was associated with increased cardiac-related events (CREs) in electroconvulsive therapy (ECT) treatment of psychiatric disorders. METHODS: The charts of 1437 ECT patients were reviewed for the presence of baseline QTc prolongation. Broadly defined CREs during the course of treatment were abstracted from patient charts. RESULTS: Presence of baseline QTc prolongation was not independent of increased risk of CREs during ECT. IMPLICATIONS: Careful consideration should be given to patients who have QTc prolongation on an electrocardiogram and are undergoing ECT treatment, but this should not definitively exclude patients from receiving ECT treatment.