Stephen J. Seiner

Safety and Efficacy of Electroconvulsive Therapy for the Treatment of Agitation and Aggression in Patients With Dementia

OBJECTIVES Noncognitive behavioral disturbances including agitation and aggression frequently accompany the cognitive symptoms of dementia accounting for much of dementias morbidity, yet treatment options are currently limited. The authors examine the safety and efficacy of Electroconvulsive Therapy (ECT) for agitation and aggression in dementia patients. DESIGN Retrospective systematic chart review. SETTING McLean Hospitals geriatric neuropsychiatry unit. PARTICIPANTS Sixteen patients with a diagnosis of dementia treated with ECT for agitation/aggression during 2004-2007. MEASUREMENTS Clinical charts were rated on the Pittsburgh Agitation Scale as the primary outcome, the Clinical Global Impression scale and the Global Assessment of Functioning pre- and post-ECT. RESULTS 16 patients of mean age 66.6 ± 8.3 years were studied. Their average overall and pre-ECT lengths of stay were 59.7 ± 39.7 days and 23 ± 15.7 days, respectively. Patients received a mean of 9 ECT treatments, mostly bilateral. Patients showed significant reductions in their total Pittsburgh Agitation Scale scores from baseline after ECT (from 11.0 ± 5.0 to 3.9 ± 4.3 [F = 30.33, df = 1, 15, p < 0.001]). Clinical Global Impression scale decreased significantly (from 6.0 ± 0.6 pre-ECT to 2.1 ± 1.6 post-ECT [F = 112.97, df = 1, 15, p < 0.001]). Global Assessment of Functioning change was not significant (from 23.0 ± 4.9 to 26.9 ± 6.9 [F = 5.73, df = 1, 13, p = 0.32]). Only one patient, in whom ECT was discontinued following 11 bilateral treatments, showed no improvement. Eight patients showed transient postictal confusion, which typically resolved within 48 hours. Two patients showed more severe postictal confusion that required modification of treatment. CONCLUSIONS These results suggest that ECT is an effective and safe treatment for agitation and aggression in dementia. Further prospective studies are warranted.

SAFETY AND UTILITY OF ACUTE ELECTROCONVULSIVE THERAPY FOR AGITATION AND AGGRESSION IN DEMENTIA

Agitation and aggression are among the most frequent and disruptive behavioral complications of dementia that contribute to increased cost of care, hospitalization, caregiver burden, and risk of premature institutionalization. This current study examined the safety and efficacy of electroconvulsive therapy (ECT) as a treatment for behavioral disturbances in dementia. We hypothesized that ECT would result in reduced agitated and aggressive behaviors between baseline and discharge.

Takotsubo cardiomyopathy after electroconvulsive therapy: a case report and review.

Takotsubo cardiomyopathy (TCM) is a syndrome of reversible stress-induced cardiomyopathy associated with profound emotional stress and a variety of medical illnesses and procedures, including electroconvulsive therapy (ECT). We describe 1 case of ECT-induced TCM followed by a successful retrial of ECT. We further discuss the management of ECT-induced TCM and the decision to perform a second trial of ECT in patients with this complication. Given the current understanding of the pathogenesis of TCM, it is appropriate to discontinue ECT during the acute setting of TCM. After the resolution of the acute episode of TCM, a second trial of ECT may be warranted depending on the severity of psychiatric illness (ie, suicidal ideation, catatonia, psychotic symptoms). If a retrial of ECT is performed, oral and intravenous &bgr;-blockers should be used for cardioprotection, and patients should be monitored for signs and symptoms of an evolving cardiomyopathy. It is preferable to perform retrials of ECT-at least initially-in a general hospital setting, where immediate invasive monitoring and intensive treatments are available in the event of acute cardiac failure.

Electroconvulsive Therapy Added to Non-Clozapine Antipsychotic Medication for Treatment Resistant Schizophrenia: Meta-Analysis of Randomized Controlled Trials

This meta-analysis of randomized controlled trials (RCTs) examined the efficacy and safety of the combination of electroconvulsive therapy (ECT) and antipsychotic medication (except for clozapine) versus the same antipsychotic monotherapy for treatment-resistant schizophrenia (TRS). Two independent investigators extracted data for a random effects meta-analysis and pre-specified subgroup and meta-regression analyses. Weighted and standard mean difference (WMD/SMD), risk ratio (RR) ±95% confidence intervals (CIs), number needed to treat (NNT), and number needed to harm (NNH) were calculated. Eleven studies (n = 818, duration = 10.2±5.5 weeks) were identified for meta-analysis. Adjunctive ECT was superior to antipsychotic monotherapy regarding (1) symptomatic improvement at last-observation endpoint with an SMD of -0.67 (p<0.00001; I2 = 62%), separating the two groups as early as weeks 1–2 with an SMD of -0.58 (p<0.00001; I2 = 0%); (2) study-defined response (RR = 1.48, p<0.0001) with an NNT of 6 (CI = 4–9) and remission rate (RR = 2.18, p = 0.0002) with an NNT of 8 (CI = 6–16); (3) PANSS positive and general symptom sub-scores at endpoint with a WMD between -3.48 to -1.32 (P = 0.01 to 0.009). Subgroup analyses were conducted comparing double blind/rater-masked vs. open RCTs, those with and without randomization details, and high quality (Jadad≥adadup analyses were Jadad<3) studies. The ECT-antipsychotic combination caused more headache (p = 0.02) with an NNH of 6 (CI = 4–11) and memory impairment (p = 0.001) with an NNH of 3 (CI = 2–5). The use of ECT to augment antipsychotic treatment (clozapine excepted) can be an effective treatment option for TRS, with increased frequency of self-reported memory impairment and headache. Trial registration CRD42014006689 (PROSPERO).

Retrospective Analysis of the Short-Term Safety of ECT in Patients With Neurological Comorbidities: A Guide for Pre-ECT Neurological Evaluations

Pre-ECT neurology consultations are often requested to determine the relative risk of the procedure in patients with neurological comorbidities, but there is limited data to guide clinicians. The authors performed a retrospective chart review of all consecutive inpatients at McLean Hospital who underwent a pre-ECT neurological evaluation between January 2012 and June 2014 (N=68). ECT was safe and effective in patients with a wide variety of neurological diseases. Only one minor event was related to a neurological comorbidity, and there were no serious neurological complications. Based on the latest evidence, the authors provide guidance on the pre-ECT evaluation with respect to neurologic status.

Common Use of Electroconvulsive Therapy for Chinese Adolescent Psychiatric Patients.

Purpose Little is known about the use of electroconvulsive therapy (ECT) for adolescent psychiatric patients in China. This study examined the frequency of ECT and the demographic and clinical correlates of adolescent psychiatric patients hospitalized in a tertiary psychiatric hospital in China. Methods This was a retrospective chart review of 954 inpatients aged between 13 and 17 years treated over a period of 8 years (2007–2013). Sociodemographic and clinical data were collected from the electronic chart management system for discharged patients. Results The rate of ECT use was 42.6% in the whole sample (46.5% for patients with schizophrenia, 41.8% for major depressive disorder, 57.8% for bipolar disorders, and 23.9% for other diagnoses). Use of ECT was independently and positively associated with older age, high aggression risk at time of admission, and use of antipsychotics and antidepressants. Compared with patients with schizophrenia, those with other psychiatric diagnoses were less likely to receive ECT. The above significant correlates explained 32% of the variance of ECT use (P < 0.001). Limitations of this study included the lack of data regarding the efficacy and side effects of ECT. Furthermore, the high rate of ECT applied only to 1 setting which limits the ability to extrapolate the implications of the results to other populations. Conclusions The use of ECT was exceedingly high in adolescent patients treated in a tertiary clinical centre in China. It is unlikely that such a high rate of ECT use is found across China or that such practice reflects standard of care for psychiatrically ill adolescents. The underlying reasons for the high use of ECT at this center warrant urgent investigations.

Electroconvulsive Therapy Alone for Schizophrenia: A Meta-analysis of Randomized, Single-blind, Controlled Trials [RETRACTED].

PURPOSE Electroconvulsive therapy (ECT) is a common treatment in practice for schizophrenia in most developing countries. This is a meta-analysis of the efficacy and safety of ECT alone versus antipsychotic (AP) monotherapy for schizophrenia using randomized, single-blind, controlled trial (RCT) data. METHODS Two assessors independently extracted data. Standardized and weighted mean difference (SMD/WMD), odds ratios (ORs) ± 95% confidence intervals (CIs), and number needed to harm (NNH) were calculated by Review Manager Version 5.3 and the Comprehensive Meta-Analysis Version 2 software. RESULTS Five RCTs (n = 365; age, 34.1 ± 4.7 years; percentage of male, 52.8 ± 9.5; range on the Jaded scale, 2-3) were identified and analyzed. Electroconvulsive therapy alone was superior to AP monotherapy with chlorpromazine, haloperidol, paliperidone, clozapine, and risperidone, respectively, regarding symptomatic improvement at last-observation end point (SMD, -0.84; P = 0.02; I = 89%). Improvement with ECT separated from AP as early as weeks 1 to 2 (SMD, -1.26; P = 0.01; I = 89%). Meta-analysis of the end point memory quotient of the Wechsler Memory Scale-Revised, Chinese version, revealed that the ECT alone group had poorer memory performance than the AP group (WMD, -9.34; P < 0.00001; I = 0%), but the difference lost its significance within 2 weeks after ECT (WMD, 0.09 to -6.54; P = 0.11-0.97; I = 0%). Compared with AP monotherapy, ECT was associated with more memory impairment (OR, 14.11; P = 0.004; NNH, 6) but with less akathisia (OR, 0.06; P = 0.0009; NNH, 6), tremor (OR, 0.08; P = 0.02; NNH, 7), and tachycardia (OR, 0.06; P = 0.006; NNH, 5). There were no significant differences in other adverse events and all-cause discontinuation. CONCLUSIONS Electroconvulsive therapy alone could be an effective and safe treatment option for schizophrenia, with transient memory impairment and headache being the major side effects.