Mimi C. Briggs

ECT in treatment-resistant depression.

Electroconvulsive therapy (ECT), which has been in use for 75 years, is an important treatment for severe and treatment-resistant depression. Although it is acknowledged as the most effective acute treatment for severe mood and psychotic disorders, it remains controversial because of misperceptions about its use and lack of familiarity among health care professionals about modern ECT technique. The authors present an illustrative case of a patient for whom ECT is indicated. They review the basic and clinical science related to ECTs mechanism of action and discuss clinical issues in the administration of a course of ECT, including the consent process.

Depression severity in electroconvulsive therapy (ECT) versus pharmacotherapy trials.

Objective We sought to compare the level of severity of depressive symptoms on entry into electroconvulsive therapy (ECT) clinical trials versus pharmacotherapy clinical trials. Data Sources English-language MEDLINE/PubMed publication databases were searched for ECT literature (search terms: ECT, electroconvulsive therapy, depression, and Hamilton) for clinical trials in which depressed patients had baseline Hamilton Rating Scale for Depression (HRSD) scores. For comparison, we used a convenience sample of 7 large pharmacotherapy trials in major depression (N = 3677). The search included articles from 1960 to 2011. Study Selection We included 100 studies that met the following criteria: ECT trial for depression, patients adequately characterized by diagnosis at baseline, and patients rated at baseline by 15-item HRSD (HRSD15), HRSD17, HRSD21, HRSD24, or HRSD28, with mean (SD) and sample size (n) reported. For the comparator pharmacotherapy trials, we chose to use a subset of the studies (excluding one study of minor depression) in the widely publicized meta-analysis of Fournier et al, as well as the STAR*D study and one additional study by Shelton et al. This provided 7 studies of major depression using HRSD17 (total N = 3677). Data Extraction Data extracted included number of subjects and baseline and final HRSD scores, with mean (SD) values. Results Of 100 ECT studies, 56 studies (N = 2243) used the HRSD17 version. The mean baseline HRSD17 score in the ECT trials was 27.6, the mean in the pharmacotherapy trials was 21.94, a statistically, and clinically, significant difference. In a subanalysis of the 16 ECT studies that used the HRSD24 version, the mean baseline score was 32.2. Conclusions This selective literature review confirms that patients who entered ECT clinical trials were more severely ill than those who entered the selected comparator pharmacotherapy trials. Such data highlight the critical role of ECT in the treatment of severe and treatment-resistant mood disorders.

Treatment-resistant postictal agitation after electroconvulsive therapy (ECT) controlled with dexmedetomidine.

Abstract Emergence agitation is a common complication of electroconvulsive therapy. Standard supportive and pharmacological interventions are usually effective management strategies. We report a case of severe agitation after electroconvulsive therapy that was refractory to the usual treatments but was controlled with dexmedetomidine.

Methohexital and succinylcholine dosing for electroconvulsive therapy (ECT): actual versus ideal.

Abstract This report compares the actual doses of methohexital and succinylcholine used for optimal anesthesia and muscle relaxation in electroconvulsive therapy with written guidelines for dosing. The initial doses of methohexital and succinylcholine in milligrams per kilogram were reviewed and compared with subsequent doses of each agent after adjustments were made for individual patient responses during treatment. The dose of methohexital required to induce general anesthesia for most patients is 1.0 mg/kg. The dose of succinylcholine required to provide adequate muscle relaxation during electroconvulsive therapy is 0.9 mg/kg, although there is considerable variability in patient response to this drug.

Appropriateness for electroconvulsive therapy (ECT) can be assessed on a three-item scale.

Electroconvulsive therapy (ECT) is the most effective and rapid treatment for severe depression; however, it should be prescribed to the limited number of patients with severe mood and psychotic disorders for whom it is clearly appropriate. We present an assessment scale that we hypothesize can be used to predict a patients appropriateness for ECT, based on the severity, heritability, and episodic nature of their depression. This scale is offered as a tool to help the practitioner and patient gain a sense of how well the patient fits the profile of someone for whom ECT is a reasonable treatment option.

Low-dose right unilateral electroconvulsive therapy (ECT): effectiveness of the first treatment.

Background Electroconvulsive therapy (ECT) is a widely used, highly effective antidepressant treatment. Except for the most severely ill patients, right unilateral (RUL) electrode placement is the most frequent initial treatment choice. In current practice, RUL ECT is administered at several multiples of seizure threshold (ST) based on reports that lower stimulus intensity results in lower response/remission rates. Many patients, as part of an initial dose titration to determine ST, will receive a single treatment with low-dose RUL ECT and subsequent treatments with a stimulus at a multiple of ST. Objective To assess response to the first ECT. Methods A retrospective analysis of charts from clinical practice at Mount Sinai Medical Center was performed. Results A single treatment with low-dose (presumably near ST) RUL ECT had a significant and immediate antidepressant effect in our sample of patients with major depression. We determined that this response is similar to that of patients receiving a single initial treatment with high-dose RUL ECT (at a multiple of ST). Conclusions These data suggest, contrary to commonly held belief, that RUL ECT may be effective at a low stimulus dose. This argues against restimulating at 6 times ST in the initial session, based on the belief that the near-threshold seizure has no antidepressant efficacy. Our findings suggest a need for further investigation of cases in which low-dose RUL ECT may be an effective antidepressant treatment. Further prospective studies, including larger numbers of patients who receive randomized treatment with low- or high-dose RUL with longer follow-up, are indicated.

Safe resumption of electroconvulsive therapy (ECT) after vertebroplasty

Vertebral compression fractures are a common injury affecting older individuals, predominantly women with osteoporosis. Although compression fractures may be asymptomatic, they frequently result in moderate-to-severe acute and chronic back pain. Fortunately, they are rarely associated with neurological dysfunction. They may occur spontaneously, or result from direct trauma, falls, or seemingly innocuous occurrences such as coughing, sneezing, or rolling over in bed. In the past, thoracic compression fractures occurred as a side effect of unmodified electroconvulsive therapy (ECT) (Kalinowsky and Hoch, 1952; Fink, 1979). With modern anesthesia techniques for ECT, compression fractures have virtually been eliminated. An 85-year-old woman with a history of treatment refractory depression was referred for ECT. This episode of depression was characterized by decreased activity, decreased energy, anhedonia, and decreased appetite. Her medical history included congestive heart failure, paroxysmal atrial fibrillation, hypertension, hypothyroidism, dementia, and alcohol abuse. Medications included donepezil, valsartan, metoprolol, digoxin, furosemide, levothyroxine, buproprion, and mirtazapine. Prior to ECT, she had complained of severe lower back pain. She reported her back pain had worsened after a fall from bed several weeks earlier. The patient underwent seven ECTs with right unilateral electrode placement. For each treatment, she received 50mg of methohexital and 60mg of succinylcholine. Excellent muscle relaxation was achieved; she evidenced minimal convulsive activity during treatment. Prior to treatment 8, she had spine X rays and a bone scan to evaluate her ongoing back pain. The X rays showed a T12 compression fracture; the bone scan showed uptake in T12, indicating an acute process. Review of computed tomography angiogram from 2weeks prior to ECT showed the compression fracture had already occurred, providing documentation that it preceded the start of ECT and was most likely from her fall from bed (Figure 1a). It was determined that she would benefit from a vertebroplasty, both to control pain and to reduce risk of further collapse. Given the presence of the compression fracture and the need to continue ECT prior to scheduling the vertebroplasty, succinylcholine was increased to 80mg for treatment 8. Two days after treatment 8, the patient underwent a vertebroplasty of the T12 vertebral body. Cement deposition into the vertebral body under anterior/ posterior and lateral fluorography was accomplished. The patient’s acute course of ECT was resumed 5 days after the vertebroplasty, and she received four additional treatments with bilateral electrode placement. For each of these treatments, she received 50mg of methohexital and 80mg of succinylcholine. She exhibited complete muscle relaxation. In total, she received 12 treatments, showing partial response, with improvement in mood and functionality, but some residual symptoms. A repeat chest X ray 1month later revealed no change (Figure 1b). We present a patient with a pre-existing vertebral compression fracture, not identified until after her course of ECT had begun. Because of ongoing pain, a decision was made to interrupt her ECT course to perform a vertebroplasty. Almost immediately following her vertebroplasty, she experienced pain relief, and we were confident that ECT could be resumed shortly after her procedure, provided complete muscle relaxation was achieved. Follow-up radiographic examination confirmed no changes from the subsequent treatments. Before the use of general anesthesia and muscle relaxation, compression fractures were a common occurrence during ECT. Spinal films were a routine component of the pre-ECT work-up. However, with the advent of modern anesthesia techniques in ECT, vertebral compression fractures are now a rare complication, resulting from sub-optimal neuromuscular blockade in at-risk patients when they occur (Weiner, 1983). Despite this, careful attention must be paid to muscular relaxation, particularly in high-risk patients with osteoporosis. Increasing the dose of succinylcholine by 40–50% (to the1.5mg/kg range) is enough to produce complete muscle relaxation in virtually any patient. Higher doses of succinylcholine may induce moderate prolongation of apnea. For maximal neuromuscular

Febrile Reaction With Elevated CPK After a Single Electroconvulsive Therapy (ECT) in an Adolescent Patient With Severe Bipolar Disorder

This report describes the electroconvulsive therapy (ECT) course of a 15-year-old male with severe bipolar disorder unresponsive to medical management. After his first treatment, the patient exhibited fever, elevated creatine phosphokinase levels, and leukocytosis. Treatment was halted although the patient reported an improvement in symptoms, which was not maintained with pharmacotherapy alone. Subsequent treatments were completed without adverse reactions, and the patient entered remission. We discuss the possible causes of this reaction and remind the reader that a single adverse event does not always require the abandonment of a treatment modality.

Transient hemiparesis (Todd's paralysis) after electroconvulsive therapy (ECT) in a patient with major depressive disorder.

We report the case of a 50-year-old man who exhibited transient left hemiparesis (Todds paralysis) after electroconvulsive therapy, which completely resolved within 10 minutes. Subsequent neurological evaluation was unremarkable for discrete etiologies for this event, other than Todds paralysis. We review the literature of this phenomenon in association with electroconvulsive therapy.

Automatic implantable cardioverter defibrillator in electroconvulsive therapy.

As the number of patients with implantable cardiac devices increases so too does the frequency with which these individuals present for electroconvulsive therapy (ECT). The rationale for deactivating an automatic implantable cardioverter defibrillator before ECT has been made based on the concern that artifacts generated during treatment could be interpreted as a treatable rhythm by the internal device, resulting in a discharge. We believe that the risk of inappropriate discharge during ECT is very low and outweighed by the considerable benefit of an active device being able to more quickly treat a malignant dysrhythmia.