Electroconvulsive Therapy Credentialing for Psychiatrists-Review of Required Standards Across States and Territories in Australia.

ABSTRACT: Electroconvulsive therapy (ECT) is a complex medical procedure, the delivery of which requires specialist knowledge and skills. We reviewed the standards required for ECT credentialing in different jurisdictions in Australia. We reviewed the Chief Psychiatrist guidelines and statewide policy standards on ECT and focused on standards required for initial credentialing and ongoing privileging in ECT. We compared the credentialing requirements within these documents with the standards specified in the Royal Australian and New Zealand College of Psychiatrists professional practice guideline for ECT. Most of the jurisdictions had specific standards for initial credentialing and maintenance of this credentialing; however, there was significant variance in the credentialing process and standards required. It would be useful to have a minimum standard for credentialing for ECT psychiatrists and prescribers. This standard would be relevant for practice of ECT internationally. States and territories would have the responsibility for implementation of these standards. Appropriate training and establishing good clinical governance processes are essential to the provision of high quality ECT.

Prescribing electroconvulsive therapy for depression: Not as simple as it used to be.

In the last century, prescribing electroconvulsive therapy usually involved considering the relative merits of unilateral versus bilateral electroconvulsive therapy, with most other parameters fixed. However, research over the last 30 years has discovered that several parameters of the electroconvulsive therapy stimulus can have a significant impact on efficacy and cognitive side effects. The stimulus dose relative to seizure threshold was shown to significantly affect efficacy, especially for right unilateral electroconvulsive therapy, where suprathreshold doses in the vicinity of 5-6 times seizure threshold were far more efficacious than doses closer to threshold. However, this did not hold for bitemporal electroconvulsive therapy, where near-threshold stimuli were equally effective as suprathreshold stimuli. Then, changes in stimulus pulse width were found to also have a significant impact on both efficacy and side effects, with ultrabrief pulse widths of 0.3 ms having significantly fewer cognitive side effects in unilateral electroconvulsive therapy than standard brief pulse widths of 1.0 ms, with only slightly reduced efficacy. Therefore, choosing the optimum electroconvulsive therapy prescription for an individual patient now requires consideration of placement, pulse width and stimulus dose relative to seizure threshold, and how these three interact with each other. This viewpoint aims to raise awareness of these issues for psychiatrists involved in electroconvulsive therapy practice.

The place of non-invasive brain stimulation in the RANZCP clinical practice guidelines for mood disorders.

Clinical practice guidelines are important documents as they have the capacity to significantly influence and shape clinical practice in important areas of therapeutics. As such, they need to be developed informed by comprehensive and quality-based systematic reviews, involve consensus deliberations representative of the appropriate experts in the field and be subject to thorough critical review. A revised clinical practice guideline for the management of patients with mood disorders was recently published under the auspices of the Royal Australian and New Zealand College of Psychiatrists. However, this clinical practice guideline was not developed in a manner that reflects the appropriate standards that should apply to clinical practice guideline development and it has critical flaws, especially as it pertains to the use of repetitive transcranial magnetic stimulation treatment for patients with depression. The revision of the college clinical practice guideline has explicitly removed clear and unequivocal evidence-based recommendations that were found in a previous version of the clinical practice guideline and replaced these with consensus-based recommendations. However, the consensus-based recommendations were developed without consultation of the appropriate expert body within the college and contradict the scientific literature. There is substantive and unequivocal evidence supporting the antidepressant use of repetitive transcranial magnetic stimulation in the treatment of patients with depression and its use after a patient with depression has failed a limited number (typically around two) of antidepressant medication trials. Readers should refer to the college Professional Practice Guidelines for repetitive transcranial magnetic stimulation published in 2018 for thorough information about the use of this important new treatment.

Cognitive effects of brief and ultrabrief pulse bitemporal electroconvulsive therapy: a randomised controlled proof-of-concept trial.

BACKGROUND: Reduction of the pulse width has been reported to improve ECT outcomes with unilateral ECT (similar efficacy, fewer cognitive side effects), but has been minimally studied for bitemporal ECT. The only study comparing brief and ultrabrief pulse bitemporal ECT found reduced efficacy for bitemporal ultrabrief compared to bitemporal brief pulse stimulation. This randomised controlled trial (RCT) aimed to test if ultrabrief pulse bitemporal ECT results in fewer cognitive side effects than brief pulse bitemporal ECT, when given at doses adjusted with the aim of achieving comparable efficacy. METHODS: Thirty-six participants were randomly assigned to receive ultrabrief (at 3 times seizure threshold) or brief (at 1.5 times seizure threshold) pulse bitemporal ECT given 3 times a week in a double-blind, controlled proof-of-concept trial. Blinded raters assessed mood and cognitive functioning over the ECT course. RESULTS: Efficacy and cognitive outcomes did not differ significantly between the two treatment groups over the ECT course. The ultrabrief pulse group performed better on a test of visual memory assessed acutely after an ECT treatment. CONCLUSIONS: This study suggests there may be a small cognitive advantage in giving bitemporal ECT with an ultrabrief pulse when dosage is increased to match the efficacy of brief pulse bitemporal ECT, but the study was underpowered to fully examine this issue.Clinical Trials Registration: www.clinicaltrials.gov, NCT00870805.

Golf cart associated traumatic brain injury.

Object: Although contact sport-related head injuries are frequently reported, golf cart accidents may have significant consequences including severe traumatic brain injury (TBI) or head injury. As no standardized regulations exist, this mechanism may be underreported. Methods: A retrospective review of TBI or cranial trauma after a golf cart accident at a level I trauma center over 5 years were performed. Data regarding age, sex, race, initial Glasgow Coma Scale score, alcohol status, type and location of the injury, and outcomes were analyzed and reported in terms of Modified Rankin Scale (MRS). Results: A total of 23 patients with TBI or cranial trauma following golf cart accident were identified. The mean age was 36 years old with the most common injury being skull fracture followed by acute subdural hematoma. Most patients had good outcomes, MRS 0-3, at discharge, but like most forms of TBI, surgical interventions, intracranial pressure monitoring, post-traumatic seizures, hydrocephalus, and death did occur. Conclusions: Head injuries sustained by golf cart accidents are not insignificant and may be underreported. More awareness of these injuries and safety guidelines are needed.

A pilot study examining the profile of older people on clozapine.

OBJECTIVE:: The primary aim was to comprehensively describe the characteristics of a cohort of older people taking clozapine. METHOD:: Participants aged ⩾ 60 had a geriatric assessment including full medical, medication and social history. Standardized screening tools for cognition, function, comorbidity and antipsychotic side effects were administered and descriptive statistics utilized. RESULTS:: Thirteen patients were eligible to participate and 10 were assessed. The mean age was 69 years. The mean clozapine dose was 309 mg/day and mean duration of use was 10 years. All participants had executive dysfunction, and half had cognitive impairment. The mean number of co-morbid conditions was five. Seven people met the criteria for polypharmacy. Eight people experienced moderate-severe antipsychotic-related side-effects. The majority demonstrated impaired physical functioning. CONCLUSIONS:: This cohort of older people taking clozapine experienced considerable morbidity, functional and cognitive impairment. We suggest routine screening of cognition and function in clozapine patients aged ⩾ 60 years. Those screening positive should be considered for further assessment by Older Person's Mental Health Services and/or a Geriatric Medicine service.

Effectiveness of Electroconvulsive Therapy and Associated Cognitive Change in Schizophrenia: A Naturalistic, Comparative Study of Treating Schizophrenia With Electroconvulsive Therapy.

OBJECTIVE: There is limited evidence regarding the relative treatment effectiveness and cognitive effects of different types of electroconvulsive therapy (ECT) in schizophrenia. In this study, we sought to determine the overall effectiveness and compare the symptomatic and cognitive outcomes of patients with schizophrenia who received different modalities of ECT treatment. METHODS: Patients received 1 of 4 of the following ECT modalities: bitemporal ECT with age-based dosing, right unilateral ECT with seizure threshold-based dosing, bitemporal ECT with seizure threshold-based dosing, and bifrontal ECT with seizure threshold-based dosing ECT. The Brief Psychiatric Rating Scale (BPRS) and Montreal Cognitive Assessment (MoCA) were administered to 62 patients before and after the ECT course. RESULTS: There was a significant improvement in both the total and psychotic subscales of BPRS and MoCA scores across the patients after the course of ECT. The global improvements in both BPRS and MoCA scores after ECT were not influenced by the type of ECT administered. Age-based dosing, however, was associated with poorer memory outcomes posttreatment. The overall symptomatic response rate, defined as 40% or more reduction in the psychotic subscale of BPRS, was 64.5%. The response rates did not significantly differ between the 4 types of ECT. CONCLUSIONS: Our present findings suggest that an acute course of ECT is effective in schizophrenia and may have cognitive benefits for some patients.

A randomized controlled trial of brief and ultrabrief pulse right unilateral electroconvulsive therapy.

BACKGROUND: Some studies suggest better overall outcomes when right unilateral electroconvulsive therapy (RUL ECT) is given with an ultrabrief, rather than brief, pulse width. METHODS: The aim of the study was to test if ultrabrief-pulse RUL ECT results in less cognitive side effects than brief- pulse RUL ECT, when given at doses which achieve comparable efficacy. One hundred and two participants were assigned to receive ultrabrief (at 8 times seizure threshold) or brief (at 5 times seizure threshold) pulse RUL ECT in a double-blind, randomized controlled trial. Blinded raters assessed mood and cognitive functioning over the ECT course. RESULTS: Efficacy outcomes were not found to be significantly different. The ultrabrief group showed less cognitive impairment immediately after a single session of ECT, and over the treatment course (autobiographical memory, orientation). CONCLUSIONS: In summary, when ultrabrief RUL ECT was given at a higher dosage than brief RUL ECT (8 versus 5 times seizure threshold), efficacy was comparable while cognitive impairment was less.

Augmentation strategies in electroconvulsive therapy.

Electroconvulsive therapy (ECT) is a highly effective treatment, but strategies to enhance therapeutic outcomes are occasionally needed. This review examines the evidence for approaches used for enhancing seizure production: hyperventilation, pretreatment with xanthines, and use of remifentanil or ketamine in ECT anesthesia. Hyperventilation may be a useful strategy to enhance seizure production, but its effects on ECT outcomes have not been systematically studied and require further research. Pretreatment with caffeine, theophylline or aminophylline (xanthines) prolongs the duration of ECT seizures but has not been clearly shown in controlled trials to increase efficacy. Caution is also warranted because their use may be associated with significant adverse effects. There are case reports of the usefulness of remifentanil in assisting seizure induction by reducing the dose of barbiturate anesthetic required, but there are no controlled data on whether it independently enhances efficacy outcomes. Preliminary evidence suggests that ketamine and ECT may have synergistic antidepressant effects, although this needs to be further examined in randomized controlled trials.

Effects of the Anaesthetic-ECT time interval and ventilation rate on seizure quality in electroconvulsive therapy: A prospective randomised trial.

BACKGROUND: The anaesthetic approach adopted in ECT practice has the potential to influence patient outcomes. However, the impact of the time interval between anaesthetic induction and ECT stimulus administration has not been studied prospectively to date. This variable may represent an indirect measure of anaesthetic concentration at the time of stimulation, and therefore may influence the quality of seizures induced. OBJECTIVE: To examine the impact of the anaesthetic to ECT stimulus time interval, and ventilation rate pre-treatment, on ictal seizure quality. METHODS: In a prospective, crossover trial, 54 depressed participants were randomised to variations in anaesthetic technique at four sequential ECT treatment sessions, in a 2 x 2 design: randomisation to a short or long anaesthetic-ECT time interval, and randomisation to normal ventilation or hyperventilation during anaesthetic induction with thiopentone. Ictal EEG data were collected at each study session and assessed by a blinded rater for ictal quality (seizure amplitude, regularity, post-ictal suppression and general seizure quality), using a quantitative-qualitative structured rating scale. Linear mixed effects models were used to analyse the effect of the anaesthetic-ECT time interval, and that of ventilation rate, on seizure quality indices. RESULTS: The anaesthetic-ECT time interval had a significant impact on ictal EEG quality indices (p < 0.01), with longer time intervals producing higher quality seizures. Ventilation rate did not significantly influence quality measures. CONCLUSION: The time between anaesthetic induction and ECT stimulus administration has a significant impact on ictal EEG seizure quality. Conversely, manipulations of ventilation rate did not significantly affect seizure quality. These results suggest the anaesthetic-ECT time interval should be routinely monitored clinically and potentially optimised for maximising seizure quality with ECT.

Spontaneous Healing of a Ruptured Blood Blister-Like Aneurysm.

BACKGROUND: Blood blister-like aneurysms (BBAs) are an uncommon group of arterial aneurysms with a high risk of rupture, progression, and repeat rupture. The best intervention is unclear; however, their clinical behavior typically requires urgent intervention. We describe a BBA managed conservatively with complete resolution found at follow-up. CASE DESCRIPTION: A 50-year-old woman presented with a Hunt-Hess grade 2, Fisher grade 3 subarachnoid hemorrhage (SAH). Computed tomography (CT) revealed mild hydrocephalus with a thick basal SAH that was eccentric to the left. The findings from CT angiography were negative. Digital subtraction arteriography (DSA) revealed a focal protuberance along the dorsal surface of the left ophthalmic segment that was concerning for a dorsal variant BBA. Repeat angiography 48 hours later demonstrated receding of the ectasia, with replacement by a <1-mm defect resembling a dorsal vessel surface fenestration. DSA 7 days after her presentation showed further healing. At 6 weeks, DSA showed no residual abnormality. CONCLUSIONS: DSA remains an important imaging study for the detection of small aneurysms, because CT angiography might not have sufficient resolution. Our unique case provides strong evidence that BBAs represent a parent artery focal dissection. BBAs can remodel over time, usually with enlargement and repeat rupture if untreated. It is possible, as we have demonstrated, that some small lesions presenting with SAH might spontaneously heal without intervention.

Cultural Assets and Substance Use Among Hispanic Adolescents.

Research on cultural factors and substance use among Hispanic adolescents has focused primarily on acculturation, while specific core Hispanic values and attributes have received minimal attention. The objective of the current study was to examine the relationship between traditional Hispanic cultural assets and substance use among adolescents. A purposive sample of 225 Hispanic adolescents (47% male) aged 13 to 16 years were recruited from community venues (e.g., park, school, mall) in a predominately Hispanic neighborhood. Participants completed a survey to assess cultural factors (familism, simpatía, respeto, and ethnic pride) and substance use in the past 3 months (alcohol and drug). Point-biserial correlations revealed significant associations of alcohol and drug use with greater familism (family connectedness), simpatía (interpersonal relationship harmony), and respeto (respect). Two stepwise binary logistic regressions were performed to evaluate the independent association between the cultural factors and substance use. The interaction of gender with each cultural factor was examined in both analyses. Simpatía emerged as the only cultural factor independently associated with alcohol use. Greater simpatía was related to abstention from alcohol. Both simpatía and familism independently correlated with drug use. Stronger endorsements of simpatía and familism were associated with absence from drug use. Interactions between cultural factors and gender were not observed. Simpatía emerged as the strongest cultural asset that may confer protection against substance use. If replicated, our results suggest substance prevention programs targeting Hispanic adolescents may benefit from the inclusion of cultural assets in the intervention paradigm.

The difficult-to-treat electroconvulsive therapy patient - Strategies for augmenting outcomes.

BACKGROUND: Several treatment strategies for augmenting outcomes with ECT (concurrent antidepressant treatment, frequency of ECT treatments, hyperventilation and use of remifentanil) are discussed in the context of a difficult clinical case, accompanied by a review of the relevant existing literature. METHODS: Literature on the above aspects of ECT technique was identified via a PubMed search and was critically reviewed. RESULTS: There is preliminary evidence that concurrent administration of some antidepressant medications may be useful in the highly treatment resistant patient, though due attention should be given to potential risks in combining these with ECT; reduction of the treatment frequency to twice a week; hyperventilation prior to each treatment; and the use of remifentanil to minimise the dosage of induction anaesthetics with anticonvulsant properties, may be useful strategies to enhance seizure production in cases where a high or rapidly rising seizure threshold is a major impediment to ECT treatment. LIMITATIONS: It should be noted that empirical evidence for the effectiveness of each of the above strategies in producing better outcomes with ECT is not definitive, pointing to the need for further research in these areas. CONCLUSIONS: The above strategies may be useful in clinical ECT practice, particularly in patients who are apparently treatment resistant, but the practitioner should be aware that the level of evidence underpinning these approaches is at present, preliminary.

Low dose lignocaine added to propofol does not attenuate the response to electroconvulsive therapy.

BACKGROUND: The addition of small amounts of lignocaine (50 mg) to propofol (200 mg) has been previously shown to reduce pain in injection, a common problem with this particular anaesthetic agent. The aim of this study was to investigate whether using the mixture of propofol plus lignocaine had any adverse effects on ECT seizure expression (duration, and ictal quality). METHOD: Ictal EEG records were retrospectively examined in 29 patients who underwent 80 pairs of ECT treatments, one given with propofol alone and one with propofol plus lignocaine. Ictal quality was manually rated for the transition from the polyspike phase to the slow wave phase, amplitude of the mid-ictal spike-and-wave phase, regularity of morphology of the predominant pattern of the slow wave phase, stereotypy, variability of the morphology and amplitude of the slow wave phase and post-ictal suppression. RESULTS: There was no significant difference in seizure duration between the two groups (33.4+/-13.0 s (propofol) vs. 33.6+/-11.2 s (propofol plus lignocaine). Furthermore although the addition of lignocaine delayed the onset of the slow wave phase by about 1s, it resulted in an improvement in three of four of the other measures of ictal quality. CONCLUSION: The addition of a small dose of lignocaine to propofol during ECT treatment enhanced rather than reduced the quality of the seizures produced.