Transient Fever Response After ECT in a Patient with Catatonic Schizophrenia: A Case Report. / Katatonik Sizofreni Hastasinda EKT Sonrasi Ortaya Çikan Geçici Ates Yaniti: Olgu Sunumu.

Electroconvulsive therapy (ECT) is an effective and safe treatment method for many psychiatric disorders. In general medical practice, ECT may cause side effects as most other treatment methods do. Headache, myalgia, nausea, vomiting, confusion, anterograde amnesia are common side effects of electroconvulsive therapy. Fever; in addition to general medical conditions such as infection, malignancy, connective tissue diseases, drug treatments, malignant hyperthermia, convulsions, it can also occur due to conditions such as neuroleptic malignant syndrome (NMS), serotonin syndrome, catatonia, malignant catatonia, which are frequently encountered in psychiatry clinics. In the literature, transient fever response due to electroconvulsive therapy application have been described, albeit rarely. Although there are many proposed mechanisms for the emergence of a fever response, regardless of its cause, it is still not understood why some fever responses occur. In this article, we present the differential diagnosis of the fever response, possible causes, and the mechanisms that may reveal the secondary fever response to electroconvulsive therapy in a case with a diagnosis of catatonic schizophrenia, who developed a fever response during electroconvulsive therapy sessions and no fever response was observed at times other than electroconvulsive therapy sessions. In this case, postictal benign fever response associated with electroconvulsive therapy was considered after excluding other medical conditions that may cause a fever response after electroconvulsive therapy. Keywords: ECT, Fever, Catatonia, NMS.

Successful Recovery of a Catatonic Patient with Severe Pneumonia and Respiratory Failure: Modified Electroconvulsive Therapy Following Tracheotomy.

BACKGROUD: Catatonia encompasses a group of severe psychomotor syndromes affecting patients' motor, speech, and complex behaviors. Common features include rigidity, reduced mobility, speech, sputum production, defecation, and eating. Risks associated with catatonia, such as increased muscle tension and reduced swallowing and coughing reflexes, along with risks from therapeutic approaches like prolonged bed rest and sedative drugs, can elevate the risk of aspiration pneumonia, severe pneumonia, and acute respiratory failure. These complications significantly impede catatonia treatment, leading to poor prognosis and jeopardizing patient safety. CASE DESCRIPTION: In this report, we present a case of catatonia complicated by severe pneumonia and respiratory failure, successfully managed with modified electroconvulsive therapy alongside tracheotomy. We hope this case provides valuable insights for psychiatrists encountering similar scenarios, facilitating the development of rational therapeutic strategies for prompt improvement of patient condition.

[Diagnosis and treatment of late-life depression]. / Diagnostic et traitement de la dépression de la personne âgée.

Late-life depression is a common pathology. The diagnosis can be difficult to make, due to intricacy of comorbidities, aging and treatments. The presentation is frequently atypical, with a high prevalence of somatic complaints. Depression is, in fact, underdiagnosed in this population and, when it is, poorly managed. This pathology constitutes a real public health problem due to impairment of functioning and quality of life, increase of comorbidities, use of health care and overall mortality, particularly by suicide. Treatment consists of psychotherapy, pharmacotherapy and/or electroconvulsive therapy.

La dépression unipolaire chez la personne âgée est une pathologie fréquente dont le diagnostic peut être difficile à poser, en raison de l'intrication des plaintes liées au vieillissement, aux comorbidités et aux traitements. La présentation est souvent atypique, avec une fréquence majorée de plaintes somatiques. Elle est, de ce fait, sous-diagnostiquée dans cette population, et lorsqu'elle l'est, souvent mal prise en charge. Pourtant, cette pathologie constitue un réel problème de santé publique par l'altération du fonctionnement et de la qualité de vie, ainsi que par la majoration des comorbidités, du recours aux soins de santé et de la mortalité globale, notamment par suicide. Le traitement est composé de psychothérapie, de pharmacothérapie et/ou d'électroconvulsivothérapie.

Molecular basis underlying changes of brain entropy and functional connectivity in major depressive disorders after electroconvulsive therapy.

INTRODUCTION: Electroconvulsive therapy (ECT) is widely used for treatment-resistant depression. However, it is unclear whether/how ECT can be targeted to affect brain regions and circuits in the brain to dynamically regulate mood and cognition. METHODS: This study used brain entropy (BEN) to measure the irregular levels of brain systems in 46 major depressive disorder (MDD) patients before and after ECT treatment. Functional connectivity (FC) was further adopted to reveal changes of functional couplings. Moreover, transcriptomic and neurotransmitter receptor data were used to reveal genetic and molecular basis of the changes of BEN and functional connectivities. RESULTS: Compared to pretreatment, the BEN in the posterior cerebellar lobe (PCL) significantly decreased and FC between the PCL and the right temporal pole (TP) significantly increased in MDD patients after treatment. Moreover, we found that these changes of BEN and FC were closely associated with genes' expression profiles involved in MAPK signaling pathway, GABAergic synapse, and dopaminergic synapse and were significantly correlated with the receptor/transporter density of 5-HT, norepinephrine, glutamate, etc. CONCLUSION: These findings suggest that loops in the cerebellum and TP are crucial for ECT regulation of mood and cognition, which provides new evidence for the antidepressant effects of ECT and the potential molecular mechanism leading to cognitive impairment.

Neurobiological mechanisms and therapeutic impact of electroconvulsive therapy (ECT).

Electroconvulsive therapy (ECT) is an efficient therapeutic resource for psycho-pharmacotherapeutic resistant forms of depression. ECT is a form of electrical brain stimulation involving the induction of a controlled seizure, clinically similar to an epileptic seizure, that is initiated in the prefrontal region of the brain and spreads to the cortex and subcortex, including the diencephalic structures. This is achieved by creating a transcranial electric field and synchronously depolarizing neuronal membranes. The mechanisms of action of ECT are not yet fully understood, but several hypotheses have been proposed to explain how it affects the brain: neurotransmitter changes, neuroplasticity, network connectivity, endocrine system regulation and changes in regional cerebral blood flow and regional metabolism.

Development, validation and clinical utility of short-term adverse-effects of electroconvulsive therapy (SAVE) checklist.

Electroconvulsive therapy (ECT) is one of the most effective treatments in psychiatry. However, it has many cognitive and non-cognitive adverse effects (AEs). There are lacunae in the literature on systematic assessment of non-cognitive AEs. There is a need for a standard, comprehensive and specific clinical tool to evaluate this. Hence, a checklist of short-term AEs of ECT (SAVE) with a 2-phase assessment was developed. Content validation was done using 15 experts' ratings and predefined content validity ratio and index (CVR and CVI) in a two-stage modified Delphi method. The checklist had a good CVR and CVI with a final tool of 39 items. The tool was sensitive and identified the non-cognitive AEs after ECT. Cardiovascular and musculoskeletal systems displayed the highest incidence. Many participants exhibited delayed recovery in orientation, gait, and stance, highlighting a necessity for meticulous monitoring. SAVE is the first standardised tool to assess short-term ECT-related AEs systematically. This checklist likely identifies clinically significant incidences of adverse effects. Its regular use may enhance the safety of ECT and patient comfort by supporting early identification and intervention for AEs. However, given the transient nature of AEs, further studies are needed to determine their predictive validity for long-term consequences.

Clinical efficacy of adjunctive esketamine anesthesia in electroconvulsive therapy for major depressive disorders: A pragmatic, randomized, controlled trial.

Electroconvulsive therapy (ECT) is an effective treatment for depression, and esketamine has been shown to have antidepressant effects. However, it is currently unclear whether adjunctive esketamine can enhance the clinical efficacy of ECT in real-world clinical practice. In this pragmatic clinical trial, patients with major depression were randomly assigned into two groups: patients received 0.25 mg/kg esketamine plus propofol (esketamine group) or the same volume of saline (control group) plus propofol. Results indicated that there was no difference in response and remission rates between the two groups. However, patients receiving esketamine had a higher remission rate of SI and lower psychotic scores. Patients receiving esketamine also required a lower electric dose, but the seizure duration and cognitive function were comparable between the two groups. Diastolic blood pressure increased after esketamine injection, but there was no increased risk of hypertension. Furthermore, incidence of delirium and confusion were comparable between the groups. Conclusively, adjunctive esketamine anesthesia does not provide any advantage in improving the response and remission rates of ECT. However, it can improve remission of SI and alleviate accompanying psychotic symptoms in depressive patients. With adjunctive usage, the adverse cardiovascular and neuropsychiatric events associated with esketamine appear to be tolerable.

Exploring Brain and Heart Interactions during Electroconvulsive Therapy with Point-of-Care Ultrasound.

BACKGROUND: Electroconvulsive therapy (ECT) is a procedure commonly used to treat a number of severe psychiatric disorders, including pharmacologic refractory depression, mania, and catatonia by purposefully inducing a generalized seizure that results in significant hemodynamic changes as a result of an initial transient parasympathetic response that is followed by a marked sympathetic response from a surge in catecholamine release. While the physiologic response of ECT on classic hemodynamic parameters such as heart rate and blood pressure has been described in the literature, real-time visualization of cardiac function using point-of-care ultrasound (POCUS) during ECT has never been reported. This study utilizes POCUS to examine cardiac function in two patients with different ages and cardiovascular risk profiles undergoing ECT. METHODS: Two patients, a 74-year-old male with significant cardiovascular risks and a 23-year-old female with no significant cardiovascular risks presenting for ECT treatment, were included in this study. A portable ultrasound device was used to obtain apical four-chamber images of the heart before ECT stimulation, after seizure induction, and 2 min after seizure resolution to assess qualitative cardiac function. Two physicians with expertise in echocardiography reviewed the studies. Hemodynamic parameters, ECT settings, and seizure duration were recorded. RESULTS: Cardiac standstill was observed in both patients during ECT stimulation. The 74-year-old patient with a significant cardiovascular risk profile exhibited a transient decline in cardiac function during ECT, while the 23-year-old patient showed no substantial worsening of cardiac function. These findings suggest that age and pre-existing cardiovascular conditions may influence the cardiac response to ECT. Other potential contributing factors to the cardiac effects of ECT include the parasympathetic and sympathetic responses, medication regimen, and seizure duration with ECT. This study also demonstrates the feasibility of using portable POCUS for real-time cardiac monitoring during ECT. CONCLUSION: This study reports for the first time cardiac standstill during ECT stimulation visualized using POCUS imaging. In addition, it reports on the potential differential impact of ECT on cardiac function based on patient-specific factors such as age and cardiovascular risks that may have implications for ECT and perioperative anesthetic management and optimization.

Mechanism of electroconvulsive therapy in schizophrenia: a bioinformatics analysis study of RNA-seq data.

OBJECTIVE: The molecular mechanism of electroconvulsive therapy (ECT) for schizophrenia remains unclear. The aim of this study was to uncover the underlying biological mechanisms of ECT in the treatment of schizophrenia using a transcriptional dataset. METHODS: The peripheral blood mRNA sequencing data of eight patients (before and after ECT) and eight healthy controls were analyzed by integrated co-expression network analysis and the differentially expressed genes were analyzed by cluster analysis. Gene set overlap analysis was performed using the hypergeometric distribution of phypfunction in R. Associations of these gene sets with psychiatric disorders were explored. Tissue-specific enrichment analysis, gene ontology enrichment analysis, and protein-protein interaction enrichment analysis were used for gene set organization localization and pathway analysis. RESULTS: We found the genes of the green-yellow module were significantly associated with the effect of ECT treatment and the common gene variants of schizophrenia ( P  = 0.0061; family-wise error correction). The genes of the green-yellow module are mainly enriched in brain tissue and mainly involved in the pathways of neurotrophin, mitogen-activated protein kinase and long-term potentiation. CONCLUSION: Genes associated with the efficacy of ECT were predominantly enriched in neurotrophin, mitogen-activated protein kinase and long-term potentiation signaling pathways.

Restoration of postictal cortical activity after electroconvulsive therapy relates to recovery of orientation in person, place, and time.

BACKGROUND: Most patients show temporary impairments in clinical orientation after electroconvulsive therapy (ECT)-induced seizures. It is unclear how postictal reorientation relates to electroencephalography (EEG) restoration. This relationship may provide additional measures to quantify postictal recovery and shed light on neurophysiological aspects of reorientation after ECT. METHODS: We analyzed prospectively collected clinical and continuous ictal and postictal EEG data from ECT patients. Postictal EEG restoration up to 1 h was estimated by the evolution of the normalized alpha-delta ratio (ADR). Times to reorientation in the cognitive domains of person, place, and time were assessed postictally. In each cognitive domain, a linear mixed model was fitted to investigate the relationships between time to reorientation and postictal EEG restoration. RESULTS: In total, 272 pairs of ictal-postictal EEG and reorientation times of 32 patients were included. In all domains, longer time to reorientation was associated with slower postictal EEG recovery. Longer seizure duration and postictal administration of midazolam were related to longer time to reorientation in all domains. At 1-hour post-seizure, most patients were clinically reoriented, while their EEG had only partly restored. CONCLUSIONS: We show a relationship between postictal EEG restoration and clinical reorientation after ECT-induced seizures. EEG was more sensitive than reorientation time in all domains to detect postictal recovery beyond 1-hour post-seizure. Our findings indicate that clinical reorientation probably depends on gradual cortical synaptic recovery, with longer seizure duration leading to longer postsynaptic suppression after ECT seizures.

Recent Advances in the Treatment of Treatment-Resistant Depression: A Narrative Review of Literature Published from 2018 to 2023.

PURPOSE OF REVIEW: We review recent advances in the treatment of treatment-resistant depression (TRD), a disorder with very limited treatment options until recently. We examine advances in psychotherapeutic, psychopharmacologic, and interventional psychiatry approaches to treatment of TRD. We also highlight various definitions of TRD in recent scientific literature. RECENT FINDINGS: Recent evidence suggests some forms of psychotherapy can be effective as adjunctive treatments for TRD, but not as monotherapies alone. Little recent evidence supports the use of adjunctive non-antidepressant pharmacotherapies such as buprenorphine and antipsychotics for the treatment of TRD; side effects and increased medication discontinuation rates may outweigh the benefits of these adjunctive pharmacotherapies. Finally, a wealth of recent evidence supports the use of interventional approaches such as electroconvulsive therapy, ketamine/esketamine, and transcranial magnetic stimulation for TRD. Recent advances in our understanding of how to treat TRD have largely expanded our knowledge of best practices in, and efficacy of, interventional psychiatric approaches. Recent research has used a variety of TRD definitions for study inclusion criteria; research on TRD should adhere to inclusion criteria based on internationally defined guidelines for more meaningfully generalizable results.

No Effect of Serum Electrolyte Levels on Electroconvulsive Therapy Seizure Quality Parameters.

INTRODUCTION: Seizure quality is considered to be associated with treatment outcomes of electroconvulsive therapy (ECT). A wide range of treatment parameters and patient characteristics are known to influence seizure quality. However, conflicting results exist for the role of serum electrolyte levels and seizure quality. METHODS: We retrospectively analyzed a total of 454 patients and a total of 2119 individual acute ECT sessions irrespective of diagnosis where a clinical evaluation of serum levels of sodium, potassium, and calcium took place routinely up to 2 days before the ECT session. To assess the impact of serum electrolyte levels on seizure quality parameters, we used mixed-effects linear regression analysis with Bonferroni correction for multiple testing. RESULTS: Serum sodium, potassium, and calcium levels were not associated with seizure quality markers after correcting the significance level for multiple testing. Younger age was consistently associated with higher postictal suppression, interhemispheric coherence, midictal amplitude, and peak heart rate. Lower dose was consistently associated with longer electroencephalogram and motor seizure duration. CONCLUSIONS: Our results suggest that there is no clinically relevant effect of serum electrolyte levels on seizure quality, at least within clinically commonly observed ranges of serum electrolyte concentrations.

High-Definition Transcranial Direct Current Stimulation-Primed Intermittent Theta Burst Stimulation in Treatment-Resistant Depression: A Controlled Study.

OBJECTIVES: The aim of this study was to evaluate whether high-definition transcranial direct current stimulation (HDtDCS) priming improves the efficacy of intermittent theta burst stimulation (iTBS) in improving TRD. METHODOLOGY: A prospective hospital-based, randomized control study where the participants were divided into active or sham HDtDCS-primed iTBS stimulation groups for a total of 10 sessions and were assessed on clinical parameters at baseline, end of week 1, and end of week 2 was done. Primary outcome of the study was the difference in Hamilton Depression Rating Scale (HDRS) scores over 2 weeks of HDtDCS-primed iTBS. RESULT: A significant effect of time was seen over HDRS scores in both active and sham groups with a large effect size. Significant effect of time was also found over the Clinical Global Impressions-Severity Scale scores of patients with a large effect size. The difference in the improvement in depressive severity as measured using HDRS and Clinical Global Impressions-Severity Scale scores between active and sham groups was also found to be significant with large effect sizes. CONCLUSION: High-definition tDCS-primed iTBS is superior to normal iTBS in patients with depression who have failed a trial of 2 antidepressants, whereas both mechanisms are of benefit to the patients.

Electroconvulsive therapy disrupts functional connectivity between hippocampus and posterior default mode network.

BACKGROUND: The mechanisms underlying memory deficits after electroconvulsive therapy (ECT) remain unclear but altered functional interactions between hippocampus and neocortex may play a role. OBJECTIVES: To test whether ECT reduces functional connectivity between hippocampus and posterior regions of the default mode network (DMN) and to examine whether altered hippocampal-neocortical functional connectivity correlates with memory impairment. A secondary aim was to explore if these connectivity changes are present 6 months after ECT. METHODS: In-patients with severe depression (n = 35) received bitemporal ECT. Functional connectivity of the hippocampus was probed with resting-state fMRI before the first ECT-session, after the end of ECT, and at a six-month follow-up. Memory was assessed with the Verbal Learning Test - Delayed Recall. Seed-based connectivity analyses established connectivity of four hippocampal seeds, covering the anterior and posterior parts of the right and left hippocampus. RESULTS: Compared to baseline, three of four hippocampal seeds became less connected to the core nodes of the posterior DMN in the week after ECT with Cohen's d ranging from -0.9 to -1.1. At the group level, patients showed post-ECT memory impairment, but individual changes in delayed recall were not correlated with the reduction in hippocampus-DMN connectivity. At six-month follow-up, no significant hippocampus-DMN reductions in connectivity were evident relative to pre-ECT, and memory scores had returned to baseline. CONCLUSION: ECT leads to a temporary disruption of functional hippocampus-DMN connectivity in patients with severe depression, but the change in connectivity strength is not related to the individual memory impairment.