Availability of Electroconvulsive Therapy in Public Health Services in the Last Decade in Brazil.

OBJECTIVE: To identify the current treatment options for electroconvulsive therapy (ECT) therapy in public services linked to the Unified Health System in Brazil and compare them with data published in 2012 based on their availability. METHODS: In this retrospective observational study, we mapped institutions that perform ECT under public health services in Brazil. A questionnaire was administered to active and inactive service centers between August 2022 and June 2023. RESULTS: We identified 16 institutions that performed ECT, including 12 linked to public universities and 4 with various links. In the last decade, 2 new public services that perform ECT in the country have emerged, whereas 4 services have ceased function. In 2022, the number of individuals treated with ECT per 100,000 population was 1.86, whereas the number of procedures performed per 100,000 people was 6.55. CONCLUSIONS: Although 2 new public ECT services have been identified, 4 have turned inactive. Most services are linked to public universities, and inactive service points to financial issues as the main factor in service interruption. Brazil has one of the lowest rates of individuals treated with ECT per 100,000 population compared with countries in North America and Europe. Thus, it is essential to raise awareness to improve ECT adoption rates and bring it out of the shadows in Brazil.

Demographics of Patients Receiving Electroconvulsive Therapy Based on State-Mandated Reporting Data.

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 the number of treating facilities was extracted. RESULTS: Data on 62,602 patients receiving treatment in 3 states (California, Illinois, Vermont) were obtained. Overall, 62.3% were women. Fewer than 1% of patients treated were younger than 18 years, whereas 30.3% were 65 years or older. White patients received a disproportionate proportion of treatments, with all other races underrepresented. The total number of facilities offering ECT in the 3 states declined over the study period. CONCLUSIONS: Recipients of ECT are more likely to be female, more likely to be elderly, and more likely to be white than the average person in their state.

An evaluation of the practice of electroconvulsive therapy (ECT) in a Victorian health service before and after the Mental Health Act 2014.

OBJECTIVE: The aim of the project was to identify changes in the practice of electroconvulsive therapy (ECT) in a metropolitan mental health service before and after the Mental Health Act 2014 (2014 Act) in Victoria. METHOD: Retrospective clinical file audit of ECT administration across all three sites at Eastern Health (EH) two years before and two years after introduction of the 2014 Act. RESULTS: There was a statistically significant decrease in the number of compulsory ECT treatments and in the number of patients who had compulsory ECT across the three hospitals at EH in the two years following the 2014 Act compared to the two years prior to the 2014 Act. There was no significant difference in the number of voluntary ECT treatments and in the number of patients who had voluntary ECT. CONCLUSION: The review showed that there has been a significant decrease in the number of compulsory ECT treatments and in the number of patients who had compulsory ECT after the introduction of the 2014 Act. Potential reasons for the changes are discussed.

[Evolution of electro-convulsive therapy activity in France since the beginning of the COVID-19 pandemic]. / Évolution de l'activité d'électro-convulsivo-thérapie en France depuis le début de la pandémie COVID-19.

The recent COVID-19 pandemic has led to major organisational changes in health care settings, especially in psychiatric hospitals. We conducted a national online survey to assess the evolution of electroconvulsive therapy (ECT) in the different centres practicing this treatment. 65 responses from all over France were analysed. More than 90 % of the centres practising ECT experienced a decrease in their activity. Half of the centres experienced a total cessation of activity and 25 % of the centres experienced a decrease of more than half of their usual activity. Post-pandemic COVID-19 psychiatric care is expected to be difficult. It is essential not to add to this difficulty the complications, often serious, that will be associated with delaying or stopping the practice of ECT. It will also be necessary to remain vigilant with regard to the specific neuropsychiatric consequences that will follow the pandemic.

Cardiac stress after electroconvulsive therapy and spontaneous generalized convulsive seizures: A prospective echocardiographic and blood biomarker study.

AIM: Knowledge about cardiac stress related to seizures in electroconvulsive therapy (ECT) and spontaneously occurring generalized convulsive seizures (GCS) is limited. The aim of the present study was to analyze cardiac function and circulating markers of cardiac stress in the early postictal period after ECT and GCS. METHODS: Patients undergoing ECT in the Department of Psychiatry, Psychotherapy and Psychosomatics and patients undergoing diagnostic video-EEG monitoring (VEM) in the Department of Neurology were prospectively enrolled between November 2017 and November 2018. Cardiac function was examined twice using transthoracic echocardiography within 60 min and >4 h after ECT or GCS. Established blood markers (troponin T high-sensitive, N-terminal pro brain natriuretic peptide) of cardiac stress or injury were collected within 30 min, 4 to 6 h, and 24 h after ECT or GCS. In the ECT group, the troponin T values were also correlated with periprocedural heart rate and blood pressure values. Because of organizational or technical reasons, the measurement was not performed in all patients. RESULTS: Twenty patients undergoing ECT and 6 patients with epilepsy with a GCS during VEM were included. Postictal echocardiography showed no wall motion disorders and no change in left ventricular and right ventricular functions. Four of 17 patients displayed a transient increase in high-sensitive cardiac troponin T 4-6 h after the seizure (3 patients with ECT-induced seizure). None of these 4 patients had signs of an acute cardiac event, and periprocedural blood pressure or heart rate peaks during ECT did not significantly differ in patients with and without troponin T elevation. CONCLUSIONS: Signs of mild cardiac stress can occur in some patients following ECT or GCS without clinical complications, probably related to excessive catecholamine release during the seizure.

Changes over time of the diagnostic and therapeutic characteristics of patients of a psychiatric intensive care unit in Austria.

OBJECTIVE: The aim of this repeated cross-sectional study was to compare patients from a psychiatric intensive care unit (PICU) over ≫30 years regarding their diagnostic and therapeutic characteristics. METHOD: Three samples including 100 consecutive inpatients each from the Viennese PICU were submitted to a chart review: sample no. 1 from the years 1985/86, no. 2 from 1995/96 and no. 3 from 2007/08. RESULTS: Changes in referral modes were associated with a decrease of patients with substance induced disorders and an increase of patients with affective disorders over time. The rate of admissions after accidents and suicides was stable. The use of cranial MRI increased, while intravenous psychopharmacotherapy and parenteral nutrition decreased. Involuntary admission occurred in 43% and in 37% of patients physical restraints were necessary. We saw a shift from tricyclic antidepressants to SSRIs and SNRIs from sample 1 to 3. Likewise, we observed the emergence of atypical antipsychotics and a reduction of use of typical neuroleptics mainly from sample 2 to 3. The percentage of patients receiving benzodiazepines increased over time, while the mean dosage of benzodiazepines decreased. 7% of patients received electroconvulsive therapy. CONCLUSIONS: The changes over time in our samples reflect the medical progress made during the last decades. Future studies should focus on evaluation of efficacy of psychiatric intensive care using standardized measurements.

Racial Disparities in the Administration of ECT in Texas, 1998-2013.

OBJECTIVE: Electroconvulsive therapy (ECT) is a treatment of choice for severe depression but has been underutilized among black patients. This study investigates racial disparities in the administration of ECT in the state of Texas between 1998 and 2013 using population data. DESIGN: Data from the Texas Department of State Health Services were obtained corresponding to the use for all ECT conducted in nonfederal settings during the period from January 2, 1998, to August 30, 2013. The data set comprised quarterly reports generated for each patient, totaling 27,931 patient quarters. Using year-by-year intercensal population estimates for the state of Texas, ECT treatments per capita were compared among black, white, Latina/Latino, and other individuals during this time period. RESULTS: Significantly more white patients were treated each quarter than minority patients (P < 0.001), with Latina/Latino patients recording fewer treatment quarters than any other racial group (P < 0.005). Large discrepancies in diagnosis by race were observed. Black patients were less likely than white and Latina/Latino patients to be diagnosed with depression and 4 times as likely as white patients to carry a diagnosis of schizophrenia. CONCLUSIONS: Concordant with previous data, large racial disparities in the administration of ECT were found in this Texas data set. Despite the limited nature of this data set, these results suggest that continued investigation is required to determine factors responsible for these disparities.

Revisiting the role of electroconvulsive therapy in schizophrenia: Where are we now?

OBJECTIVE: The purpose of this opinion article is to review the recent evidence base in relation to the role of electroconvulsive therapy (ECT) in the management of patients with schizophrenia. Specifically, we explore the efficacy and safety of ECT. Furthermore, consideration is given to the profile of patients who benefit most from ECT, the role of maintenance ECT and what happens when ECT is not given. CONCLUSION: Our brief review of the evidence suggests that clinical practice in developing countries has not kept up with the growing literature supporting ECT use in schizophrenia. As such, we advocate that ECT should not be a treatment of last resort. Rather, it should be considered more readily as an add-on therapy when there has been a poor response to antipsychotic medications or concerns exist about side effects. Further research is needed into the efficacy of maintenance ECT.

Traumatic shock and electroshock: the difficult relationship between anatomic pathology and psychiatry in the early 20th century.

In the conviction that a look at the past can contribute to a better understanding of the present in the field of science too, we discuss here two aspects of the relationship between early 20th century anatomic pathology and psychiatry that have received very little attention, in Italy at least. There was much debate between these two disciplines throughout the 19th century, which began to lose momentum in the early years of the 20th, with the arrival on the scene of schizophrenia (a disease histologically sine materia) in all its epidemiological relevance.The First World War also contributed to the separation between psychiatry and pathology, which unfolded in the fruitless attempts to identify a histopathological justification for the psychological trauma known as shell shock. This condition was defined at the time as a "strange disorder" with very spectacular symptoms (memory loss, trembling, hallucinations, blindness with no apparent organic cause, dysesthesias, myoclonus, bizarre postures, hemiplegia, and more), that may have found neuropathological grounds only some hundred years later.Among the doctors with a passed involvement in the conflict, Ugo Cerletti, the inventor of electroshock treatment, focused on the problem of schizophrenia without abandoning his efforts to identify its organic factors: if inducing a controlled electric shock, just like an experimentally-induced epileptic seizure, seems to allay the psychotic symptoms and heal the patient, then what happens inside the brain? In seeking histological proof of the clinical effects of electroconvulsive therapy ("the destruction of the pathological synapses"), and attempting to isolate molecules (that he called acroagonins) he believed to be synthesized by neurons exposed to strong electric stimulation, Cerletti extended a hand towards anatomic pathology, and took the first steps towards a neurochemical perspective. However his dedication to finding a microscopic explanation for schizophrenia - in the name of a "somatist" approach that, some years earlier, the psychiatrist Enrico Morselli had labelled "histomania" - was unable to prevent psychiatry from moving further and further away from anatomic pathology.

Tranylcypromine Plus Amitriptyline for Electroconvulsive Therapy-Resistant Depression: A Long-Term Study.

BACKGROUND: Few therapeutic options are available for patients with electroconvulsive therapy-resistant major depressive disorder (ECT-r MDD), leaving a substantial proportion of this population beyond treatment possibilities. The combination of monoamine oxidase inhibitors and tricyclic antidepressants could be a potential strategy for managing ECT-r MDD, and the specific association of amitriptyline and tranylcypromine may offer additional tolerability advantages. Although promising, in our knowledge, no studies have examined until now the effectiveness of this combination in ECT-r MDD. METHODS: We report a retrospective cohort of 31 patients with ECT-r MDD treated in an open-label fashion with the combination of amitriptyline and tranylcypromine. RESULTS: Overall, 80.6% of the sample met response criteria at the end of the first 12 weeks of treatment. Seventy-six percent (19 of 25) of the responders were followed for a mean of 9.37 ± 3.86 years. During this follow-up period, none of the patients had a recurring depressive episode. The combination was well tolerated, whereas minor adverse effects were common, and no severe or life-threatening events were reported throughout the study. CONCLUSIONS: These findings indicate that the combination tranylcypromine and amitriptyline is a potentially safe and effective candidate for future investigation in the treatment and long-term maintenance of ECT-r MDD.

Remission rate of transcranial magnetic stimulation compared with electroconvulsive therapy: a case-control study.

PURPOSE: To compare the rate of remission, rate of response, change in depressive symptoms, and adverse effects between repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT). MATERIALS AND METHODS: In this retrospective case-control study, 35 patients treated for depression with rTMS (left dorsolateral prefrontal cortex, 90% observed motor threshold, 10 Hz, 2000 pulses/session, 15 sessions) at Örebro University Hospital, Sweden (cases), were compared with a matched group of 35 patients treated for depression with ECT (controls). Data on controls were obtained from the Swedish National Quality Register for ECT (Q-ECT). Severity of depression was evaluated using the Montgomery-Åsberg Depression rating scale (MADRS). RESULTS: Remission rate was 26% for cases and 43% for controls (p = .3). Response rate was 40% for cases and 51% for controls (p = .63). The median decrease in MADRS was 11 (IQR 3-19) vs. 17 (IQR 6-27; p = .10) for rTMS and ECT, respectively. There was no statistically significant difference in any measure of treatment effect between rTMS and ECT. More than half of the patients of the rTMS group experienced scalp discomfort and 11% of the ECT group had memory disturbances. CONCLUSIONS: All measures of therapeutic efficacy were numerically inferior in the rTMS group compared to the ECT group. The differences were not statistically significant, probably because the sample size was small. More studies are required to find the optimal place for rTMS within the Swedish health care system. Such studies could be facilitated by inclusion of rTMS in the Q-ECT.

[Rationality and freedom in medicine: the case of electroconvulsive therapy]. / Rationalität und Freiheit in der Medizin: Der Fall der Elektrokrampftherapie.

There are no rational reasons why electroconvulsive therapy (ECT) should not be subject to the same criteria in its clinical application as any other treatment in medicine. Associations referring to historical events and their presentation in the media do not provide convincing arguments against the clinical use of ECT. In order to offer ECT to patients, scientifically solid evidence with respect to its clinical results must be available. As this scientific evidence is clearly given, ECT must be offered to the patients. A well-informed, reflected medicine must not withhold an effective treatment like ECT from the patients and medicine should not be influenced by associations but only by scientific evidence, even though the exact mechanisms of action of ECT are not known in detail. The image of ECT has clearly improved during the last decades thereby increasing the hope that unjustified arguments against ECT will lose their impact.

ECT: a new look at an old friend.

PURPOSE OF REVIEW: Electroconvulsive therapy (ECT) as a treatment option in psychiatry is advancing day by day. This review discusses new advancements in ECT with regards to anesthetic variables, stimulus, and response variables along with their impact on clinical outcomes. RECENT FINDINGS: Anesthetic variables influence clinical efficacy and patient tolerance of ECT. Although etomidate or a ketamine-propofol combination may be the first choice for many clinicians, the search for ideal induction agent continues. Dexmedetomidine, remifentanil, or ketamine may aid in augmentation of ECT; however, they are not recommended routinely. A systematic procedure for hyperventilation of the patient has been shown to have clinical repercussions. Optimizing anesthesia-ECT time interval (ASTI) has a significant impact on the success of the procedure. BIS monitoring alone cannot be relied upon for timing stimulus. High-dose brief pulse right unilateral ECT represents an acceptable first-line form of treatment, though there is currently no 'gold standard'. Other stimulus variations such as focal electrically administered seizure therapy, individualized low-amplitude seizure therapy, magnetic seizure therapy, left unilateral and left anterior right temporal electrode placements are explored to reduce memory effects. EEG ictal indices may be relied upon for seizure adequacy, and therefore may be used to both guide treatment and predict the outcome of the procedure. SUMMARY: Modern ECT is streamlined by augmentation with drugs, hyperventilation, optimizing anesthesia-ECT time interval, and various stimulus parameters guided by seizure adequacy markers.

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.

Changes in Electroconvulsive Therapy Practice in the Last 12 Years in Hungary.

BACKGROUND: Electroconvulsive therapy (ECT) was rarely used in Hungary in 2002, and the majority of patients receiving ECT were diagnosed with schizophrenia. This study aimed to explore the use of ECT in Hungary in 2014. METHODS: Two semi-structured questionnaires were sent to all acute adult psychiatric units in Hungary. The first questionnaire contained items concerning ECT use, and the second explored the reasons for not using ECT. RESULTS: Fifty-eight acute psychiatric inpatient units were identified, and 54 replied. Although 27 indicated that they used ECT, only 22 actually performed ECT in 2014. Thirty-one units did not offer ECT at all. In 2014, 174 patients received ECT in Hungary, constituting 0.59% of all inpatients treated in the departments where it was offered, equating to 0.176 patients/10,000 population. The indication for ECT shifted from schizophrenia in 2002 (55.6%) to mood disorders in 2014 (58.5%), but the absolute number of ECT-treated patients with mood disorders (110 vs 102) did not change. Reasons for not using ECT included the lack of an ECT machine, unavailability of an anesthesiologist, lack of finances, and lack of experienced staff. CONCLUSIONS: In view of the high frequency of depression and suicide in Hungary, it is very likely that a significant minority of patients who would benefit from ECT cannot access it, which constitutes a violation of their right to the best possible treatment. The main reasons for the inadequate ECT service are the underfinanced hospital system and a lack of necessary knowledge.

A Further Decrease in the Rates of Administration of Electroconvulsive Therapy in England.

OBJECTIVES: Electroconvulsive therapy (ECT) is an effective treatment of major depression, and there have been consistent improvements in the administration of ECT in the past decade. However, studies have reported a steady decline in the rates of use of ECT in the United Kingdom and Ireland. Despite this, there has been no consistent record of how much ECT is being given or to whom it is given, for more than 20 years. The purpose of this study is to estimate the change in frequency of ECT use, the length of courses, patient demographics, and clinical outcomes between 2006 and 2 periods of 2012/2013 and 2014/2015. METHODS: In 2012/2013, clinics were asked to complete an online survey giving details of every patient who started a course of ECT between April 1, 2012, and March 31, 2013. This was repeated for the same period in 2014/2015. RESULTS: There continues to be a striking decline in the number of courses of ECT prescribed. Course length has increased. Women are twice as likely to be prescribed ECT as men. Modal age is 60 to 80 years, and the most common diagnosis is depression. Most courses were rated as clinically effective, especially for people with severe illnesses. Maintenance ECT is used at half the clinics surveyed. CONCLUSIONS: The use of ECT in England continues to decline. The reasons for this are unclear and need investigation.

Time Trends and Variations in Electroconvulsive Treatment in Denmark 2008 to 2014: A Nationwide Register-Based Study.

OBJECTIVE: The aim of this study was to determine status and variations in the practice of electroconvulsive treatment (ECT) in Denmark in patient characteristics, indications, treatment patterns, and hospital region. METHOD: All 140,627 ECTs registered in the Danish National Patient Registry between 2008 and 2014 were retrieved together with information on patient characteristics. Annual treated person rates were calculated for sex, age, admission diagnosis, and region. RESULTS: The overall ECT treatment rate was 36 (95% confidence interval, 34-38) per 100,000 resident population during the study period. The rate was highest in women and increased with age. There were modest, however, stable regional differences in rates (extremal quotient = 1.4). Electroconvulsive treatment was most commonly used in patients with depression with (19.4%) or without (54.9%) psychotic symptoms. The median number of ECTs administered per patient was 10 and highest in patients with schizophrenia, schizoaffective, or bipolar disorders. A total of 51%, 14%, and 33% of ECTs were administered with bilateral, unilateral, and unspecified electrode placement, respectively. There were regional differences in electrode placement specification and use. CONCLUSIONS: Although some variation was seen across hospital regions and electrode placement, ECT in Denmark was provided with relative stability over time and indications compared with most other countries in Europe and North America.

Improvement of cycloid psychosis following electroconvulsive therapy.

BACKGROUND: The treatment of choice for cycloid psychosis has traditionally been electroconvulsive therapy (ECT), but there is a lack of studies on its effectiveness. AIMS: The primary aim of this register study was to determine the rates of remission and response after ECT for cycloid psychosis. The secondary aim was to examine possible predictors of outcome. METHODS: Data were obtained from the National Quality Register for ECT in Sweden. The study population was patients (n = 42) who received ECT for acute polymorphic psychotic disorder without symptoms of schizophrenia or for cycloid psychosis between 2011-2015 in 13 hospitals. Remission and response rates were calculated using Clinical Global Impression-Severity (CGI-S) and -Improvement scores, respectively. Variables with possible predictive value were tested using Chi-square and Fisher's exact test. RESULTS: The response rate was 90.5%. The remission rate was 45.2%. Of 42 patients, 40 improved their CGI-S score after ECT (p < 0.001). The mean number of ECT treatments was 2.5 for non-responders and 7.0 for responders (p = 0.010). The mean number of ECT treatments did not differ significantly between remitters and non-remitters (7.2 vs 6.1, p = 0.31). None of the other investigated potential predictors was statistically significantly associated with outcome. CONCLUSIONS: ECT is an effective treatment for cycloid psychosis. Future studies need to compare the outcome of ECT to that of other treatment strategies. CLINICAL IMPLICATIONS: The high response rate with ECT indicates that cycloid psychosis is a clinically useful diagnosis.

[Electroconvulsive therapy in the Netherlands: the practice in 2015 compared to that in 2008]. / Elektroconvulsietherapie in Nederland: de praktijk in 2015 vergeleken met die in 2008.

BACKGROUND: The most recent information about the use of ECT in the Netherlands dates from 2008. An update version of the guideline for the use of ECT in the Netherlands was issued in 2010. AIM: To obtain insight into the practice of ECT in the Netherlands five years after implementation of the guideline. METHOD: Our study is based on a questionnaire about the use of ECT by psychiatrists in all Dutch institutions (n=33). Questions concerned the use and availability of ECT as well as the implementation of the updated guideline; they also served as a check on the expertise and training of ECT-psychiatrists. RESULTS: All institutions responded. The total number of ECT-sessions performed in 2015 was 15,633, a 16% increase compared to 2008. In 2015 more institutions were using 7x24 ECT and more had an ECT-nurse available. Nearly all psychiatrists were acquainted at the time with the revised guideline of 2010 and nearly 50% of them had adjusted the way they practised ECT. However, just under 40% of psychiatrists did not have the correct knowledge about some technical details regarding ECT. CONCLUSION: The revised guideline on ECT and its implementation have most likely improved the practice of ECT in the Netherlands.

Long-term Effectiveness of Modified Electroconvulsive Therapy Compared With Repetitive Transcranial Magnetic Stimulation for the Treatment of Recurrent Major Depressive Disorder.

This retrospective study recruited 150 patients with recurrent major depressive disorder (MDD) who received modified electroconvulsive therapy (MECT) and 150 cases treated with repetitive transcranial magnetic stimulation (rTMS), which aimed to compare the short- and long-term effectiveness, as well as economic outcomes, of MECT and rTMS with a large sample size in patients with recurrent MDD. The results showed that the response rate of patients in the rTMS group was lower than that in the MECT group (46.0% vs 58.7%, p < 0.05). Patients in the rTMS group had elevated rate of dizziness, but reduced rates of poor memory and headache, as well as lower costs compared with the MECT group (p < 0.05). Importantly, we found that the relapse-free survival of patients was similar between the rTMS and MECT groups in the long term. In conclusion, rTMS is an alternative method for MECT in the treatment of patients with recurrent MDD.