Catatonia.

Patients with treatment resistant schizophrenia (TRS) may benefit from electroconvulsive therapy (ECT). Although TRS is a frequent problem in forensic hospitals, ECT is rarely used in this setting. This study investigates the availability and implementation of ECT in forensic hospitals in Germany and Switzerland. Moreover, we collected anonymized clinical data of patients treated with ECT. A digital survey was sent to all forensic psychiatric hospitals in Germany and Switzerland. The questionnaire comprised general information (hospital structure, use of ECT) and an optional second part for patients treated with ECT during the last 12 months. 41 German and 4 Suisse hospitals responded, of which the majority stated to have the possibility to offer ECT. The estimated percentage of patients with ECT indication was 7.35% (360 patients) and 7.5% (13 patients), respectively. However, only 38 patients were actually treated with ECT over a period of 12 months. Slightly over 50% of the patients were responders according to the Clinical Global Impression Improvement Scale. Our study presents the largest population of patients with TRS treated with ECT in forensic hospitals to date. Compared to 2018, there was a marked increase in the proportion of patients for whom ECT was considered indicated. Patients treated with ECT experienced a reduction in both symptom severity and the need for restraints. The response rate aligns with matching data from non-forensic populations. In view of these promising results, prospective controlled observational studies are needed to further strengthen the evidence regarding the effectiveness of ECT in forensic populations.

Electroconvulsive therapy (ECT) is the most effective treatment for severe depression and is often the last resort in patients with medically treatment-resistant depression.1 The clinical effect of ECT relies upon the quality of the seizures elicited.2 In a patient not responding to ECT due to poor seizure quality, eliciting an adequate seizure may be the initial challenge. Anesthesia influences seizure quality.3 Etomidate is an ultrashort-acting, non-barbiturate hypnotic intravenous anesthetic agent with minimal cardiovascular effects, making it suitable for ECT. Etomidate lacks the strong anticonvulsant properties of standard ECT anesthetics (i.e., thiopental and propofol4) and leads to higher-quality and longer seizures.5 However, etomidate inhibits 11β-hydroxylase and steroid biosynthesis, including corticosteroids.6 A major concern is the potential for adrenocortical suppression in rapid-sequence induction of anesthesia in critically ill patients. We present a patient who had null seizures at the maximal stimulus dosage until a change in anesthesia to etomidate, and review the literature on the effect of anesthesia on ECT seizure quality. A 61-year-old man with recurrent major depressive disorder was hospitalized due to moderate depression with suicidal ideation (17-item Hamilton Depression Rating Scale [HAM-D] score = 21). Several treatment regimens with combinations of antidepressants failed, and he consented to ECT. ECT was administered thrice weekly (Table 1). The initial three ECT sessions with rising stimulation doses to the maximal 1021 mC with 3.5-mg/kg thiopental as standard anesthesia completely failed to elicit a seizure. Even 0.5-mg alfentanil augmentation and 50 mg chlorprothixene the evening before ECT to lower the seizure threshold had no effect. Anesthesia was changed to 0.2 mg/kg etomidate and elicited high-quality seizures of >60 s with clinical effect (HAM-D score = 16 after seven seizures), which allowed a down-titration of stimulus, potentially reducing the associated cognitive side-effects of ECT. The patient received 11 high-quality and clinically effective ECT treatments as an inpatient. He was discharged shortly after with fewer depressive symptoms (HAM-D score = 9) and was followed up in outpatient care with once-weekly maintenance ECT. The morning before his 25th maintenance ECT, his serum cortisol was 179 nM and the following morning 212 nM, which is higher than the minimum expected morning plasma cortisol concentration of 133 nM. Similarly, 24-h measurement of total urine cortisol production after the 25th ECT was 101 nmol (reference interval 10–124 nmol), indicating no adrenal suppression. At one of the ECT sessions, after etomidate administration, he had limb contractions before a muscle relaxant was administered. The contractions were confused with a seizure and lasted for ~30 s before termination with 5 mg diazepam and ECT was aborted. Follow-up MRI, electroencephalography (EEG), and neurological assessment concluded that the contractions were myoclonus due to late injection of the muscle relaxant. The patient received 26 successful ECT treatments with etomidate and gave written consent to publishing this case report. We present how etomidate enabled high-quality seizures in a patient unresponsive to ECT during standard thiopental anesthesia. Although >35 treatments using etomidate were given, the patient showed no signs of corticoadrenal suppression in terms of lower circulating levels of cortisol. This is in line with evidence that, although three ECT sessions weekly constitutes repeated use of etomidate in a relatively short time interval, serum levels of cortisol and adrenocorticotropin do not reach abnormally low levels during or after a sequence of ECT with etomidate in this patient population.7 Myoclonus is a very common side-effect during induction with etomidate and can be misinterpreted as a seizure. Unlike thiopental and propofol, which have strong anticonvulsant properties; etomidate has a disinhibitory effect on extrapyramidal motor activity responsible for the majority of myoclonus observed. A more specific and potent etomidate analogue was abandoned during phase II studies due to involuntary muscle movements.8 While involuntary muscle movements are undesirable in a non-ECT setting, they may be desirable for ECT as the cortical disinhibitory effect may be what enables etomidate to provide higher-quality seizures. Etomidate leads to higher-quality seizures and longer motor seizures in ECT.5, 9 In the most recent review of anesthesia for ECT, etomidate and ketamine yielded the longest seizures.3 The same review found that etomidate and a 1:1 (racemic)-ketamine and propofol mixture yielded the highest-quality seizures. The only comparison between etomidate and s-ketamine suggests that s-ketamine showed no difference in seizure duration but may provide higher-quality seizures based on higher postictal suppression, EEG coherence, ictal amplitude, and peak heart rate.10 Given the limited study size and adverse side-effects of s-ketamine (i.e., dissociative symptoms, vomiting, and hypertension), etomidate appears favorable. Our case highlights the impact of anesthesia on seizure generation during ECT, and how etomidate, largely abandoned in intensive care settings, may be considered the anesthetic of choice when patients fail to achieve high-quality seizures and clinical effect during ECT. All authors declare that they have no financial interests or any other conflict of interest with other people or organizations that could inappropriately influence this work.

The present study is the first large-scale, multicenter survey on modified electroconvulsive therapy (ECT) in Japan. We aimed to comprehend the current implementation status of ECT based on the annual reports of 2016 from 21 facilities that were certified by the Japanese Society of General Hospital Psychiatry as ECT certified facilities and participated in this multicenter observational study. We investigated the distributions of diagnosis, gender, and age of patients receiving acute-phase ECT, and the efficacy, safety, and adverse events. The number of patients receiving acute-phase ECT was 524. According to International Classification of Diseases, 10th Revision, 344 patients (65.6%) were diagnosed with mood disorders (F3), 156 patients (29.8%) were diagnosed with schizophrenia and with schizotypal and delusional disorders (F2), and 151 subjects were male and 334 subjects were female. The mean age of patients was 60.4 years (SD 15.9), and patients 60 years or older accounted for 57.9%. Efficacy did not significantly differ between diagnoses, nor between genders. However, the efficacy rate was significantly higher in elderly patients. In acute-phase ECT, 4 severe adverse events occurred. Our multicenter study confirmed that F3 (mood disorders) was the most common indication for ECT at 66%, followed by F2 (schizophrenia, schizotypal, and delusional disorders) at 30%, with no difference in efficacy, indicating that ECT is still performed as 1 of the treatment options for schizophrenia in Japan. The present results suggested that accumulation of annual data from multiple centers can be useful for more effective and safer ECT practices.

IntroductionElectroconvulsive therapy (ECT) is a recognized treatment for various psychiatric conditions (Bernardo et al., 2018). However, there is a lack of recent studies describing the clinical characteristics of patients undergoing ECT (Peltzman et al., 2020).ObjectivesTo provide an updated evaluation of the clinical characteristics, treatment parameters, and outcomes of patients receiving ECT at Clinica Universidad de Navarra (CUN), focusing on its effectiveness and evolution over recent years.MethodsThis cross-sectional descriptive study examines patients who underwent electroconvulsive therapy (ECT) at CUN’s Psychiatric Hospitalization Unit from January 2019 to August 2023. It focuses on those who received bifrontotemporal ECT, with stimulation power quantified using the DGx program on the Thymatron® machine. Collected data include age, sex, prior psychotropic medication use, ECT indication, comorbidities, Stimulus potency (%DGx), seizure duration (seconds on the electroencephalogram), and anesthetic induction type. Hamilton Anxiety and Depression Scales were recorded before and after treatment when clinically indicated.ResultsECT was administered in 80 cases, constituting 8.62% of admitted patients, with 33.75% being male. Among these, 33% had psychiatric comorbidities, most commonly being pathological personality traits (16%) and generalized anxiety disorder (5.3%) (Image 1). Non-psychiatric comorbidities included endocrine-metabolic conditions 49% and cardiac conditions 34% (Image 2.)Pre-ECT, the most common psychotropic medications included benzodiazepines (87.5%), atypical antipsychotics (76.5%), and dual antidepressants (47.5%). Propofol was used for initial anesthetic induction in 86.25% of cases, with 30.43% requiring a switch to thiopental due to the reduced efficacy. The average number of ECT sessions per patient was 8.9 (range: 3-13), with a mean seizure duration of 30.5 seconds. The primary indications for ECT were depressive disorders (85%) and psychotic disorders (11%) (Image 3).Before ECT, the average Hamilton Depression Scale score was 25.3, decreasing to 5.3 post-treatment. Similarly, the Hamilton Anxiety Scale score average was 23.72 before ECT and 4.6 after.Image 1:Image 2:Image 3:ConclusionsOur sample revealed that the primary indications for ECT were affective and psychotic disorders, with a predominant impact on adult women. This supports its role as a key intervention for treatment-resistant conditions, a finding consistent with existing literature (Leiknes et al., 2012). These preliminary results represent an initial evaluation in a broader study aimed at exploring additional aspects of clinical response and comparing ECT with other treatment modalities.Disclosure of InterestNone Declared

The chapter discusses a project which studied four mental hospitals in each of the Allied occupation zones directly after the end of World War II. During the war, these hospitals had been converted into centres for killing ‘useless mouths’ by the Nazi government. The author examines the dire situation found in these asylums by the Allies when they arrived to occupy Germany, and how it changed over the following years. First of all, starvation was still common in the immediate post-war years. Second, new forms of treatment, such as electroconvulsive therapy, psychotropic drugs and psychotherapy were gradually being adopted. Third, although patients diagnosed with ‘schizophrenia’ in its various forms still made up the largest patient group in the asylums, their numbers declined while the number of patients with psychiatric diseases related to old age increased in three of the four asylums under study. Fourth, the changes in the patient groups did not lead to major changes in the distribution of social classes across the asylums’ patient populations – class distribution was more or less the same as it was in the general population. By the early 1950s, changes in the four asylums reflected the ways in which they were trying to lose the stigma of having once been killing centres under the National Socialist rule.

To the Editor: Thank you for the opportunity to respond to the valuable comments on the study on relative effectiveness of electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS) (reference to the letter to the editor). Indeed, it is important to be reminded that this study, with its observational design, cannot, with certainty, answer the question about the superiority of ECT or rTMS, as randomized studies can.1 In order to respond to the comments, the still expanding registers were revisited, and further analyses were made that could shed more light on the relative effectiveness of ECT and rTMS. As noticed in the Letter to the Editor, the current study had a risk of being biased toward a higher chance for ECT to show positive effects in patients with depression because the majority of patients received ECT as the first treatment. Thus, we extracted a new dataset with a population of patients who received both rTMS and ECT and who were treated with rTMS first. All patients were assessed with the Montgomery-Åsberg Depression Rating Scale–Self-assessment (MADRS-S) before and after both treatments. In total, 128 patients were identified. Patients were treated between 2018 and 2023 (data extraction was done on the 15th of December 2023). The mean of the MADRS-S score before rTMS was 33.6 (SD, 7.4) and 28.3 (SD, 10.3) after rTMS. The mean of the MADRS-S score before ECT was 34.7 (SD, 7.7) and 20.8 (SD, 11.1) after ECT. A linear mixed model was used to analyze the significance of differences between MADRS-S change after rTMS and ECT while accounting for the intraindividual variability. The best-fitting model included a random intercept and a random slope. The interaction term between MADRS-S change and ECT versus MADRS-S change and rTMS was significant (P < 0.0001), meaning that patients improved significantly more after ECT compared with after rTMS. The new result of the new analysis suggests that the published study was not significantly biased because the majority of patients received ECT first. These results should also be seen in the broader context of the evidence based on randomized studies supporting the idea of the superiority of ECT over rTMS in treating major depression.2,3 However, more randomized studies are needed to compare the effects of these 2 treatment modalities in different subpopulations with depression. Considerations should include costs and patient preferences after balancing antidepressive effects with adverse effects. Katarzyna Popiolek, MDUniversity Health Care Research CentreFaculty of Medicine and HealthÖrebro UniversityÖrebro, Sweden[email protected]Tor Arnison, PhDUniversity Health Care Research CentreFaculty of Medicine and HealthÖrebro UniversityÖrebroSwedenRobert Boden, MD, PhDDepartment of Medical SciencesPsychiatryUppsala UniversityUppsalaSwedenCarl Johan Ekman, MD, PhDJohan Lundberg, MD, PhDCentre for Psychiatry ResearchDepartment of Clinical NeuroscienceKarolinska Institutet and Stockholm Health CareServicesRegion StockholmSwedenPontus StrandbergSchool of Medical SciencesÖrebro UniversityÖrebroSwedenAxel Nordenskjöld, MD, PhDUniversity Health Care Research CentreFaculty of Medicine and HealthÖrebro UniversityÖrebroSweden

Pattern of electroconvulsive therapy use in Spain: Proposals for an optimal practice and equitable access

Management of Psychiatric Disorders during the Perinatal Period.

IntroductionElectroconvulsive therapy (ECT) is a life-saving procedure in certain psychiatric conditions and is also extremely effective for treatment resistant psychiatric conditions. Despite the proven safety and efficacy there appears to be unease and stigma attached to ECT. Exploration about the awareness and attitudes regarding ECT among patients and caregivers can improve the practice of ECT. AimsThe aim of this study was to describe awareness and attitudes about ECT among patients and their caregivers. MethodsThis was a descriptive cross-sectional study carried out among patients and caregivers attending psychiatric facilities at a tertiary care hospital in Sri Lanka, using an interviewer administered questionnaire. ResultsOut of 221 participants, 54% were caregivers. Among the participants, 65% thought that ECT is a treatment used for psychiatric disorders. There was no significant association between educational level and awareness about ECT (p&gt;0.05). The most common source of knowledge about ECT was doctors (43%), but 69% felt doctors have not explained about ECT prior to treatment. Cognitive issues (46%) were the most commonly feared side effect; 5% thought ECT does not have a scientific basis and 20% felt it is an inhuman mode of treatment. Of those interviewed, 38% were of the opinion that they would receive ECT if recommended. ConclusionsDoctors were the most important source of information regarding ECT and a significant proportion of the participants knew that it is used in treating psychiatric disorders. Only a minority thought ECT didn’t have a scientific basis and a considerable proportion were willing to undergo ECT if recommended. Despite popular beliefs this cohort of participants appeared to have a favourable awareness about ECT.

Cost-effectiveness modeling of repetitive transcranial magnetic stimulation compared to electroconvulsive therapy for treatment-resistant depression in Singapore

The pioneer study of A. B. Hollingshead and F. C. Redlich, recorded in their book, Social Class and Mental Illness, indicates that social class is related to a number of factors pertaining to mental illness. Subsequent studies prompted by this work have examined some of these factors. All of these investigations were carried out in the United States in various mental health settings. It became our purpose to examine the relevance of these factors in a Canadian mental hospital setting. Three hypotheses were postulated. First, that social class would be related to the type of treatment received in the hospital. Second, that the duration of stay in the hospital would be related to social class. And, third, that the patient's level of improvement upon discharge from the hospital would be related to social class. Routinely collected data from Riverview Provincial Mental Hospital were used to test these hypotheses. No statistically significant relationships were found between social class and of the three dependent variables. However, it was noted that the higher social class levels of psychotics, as measured by the educational index, seemed to receive more electro-convulsive therapy and group therapy than was the case with any other diagnostic category. Possibly this trend could be persued in subsequent studies. Also, duration of stay was not considered to be an important variable because of the relatively short stay of the majority of all persons admitted to the hospital. It was concluded that the definition of treatment was too narrow. Electroconvulsive therapy and group therapy were the most amenable to statistical examination. However, it is widely recognized that milieu therapy is a major form of treatment in Riverview Hospital and therefore, should be included in any consideration of treatment in subsequent studies.

Reviewed by: Managing Madness: Weyburn Mental Hospital and the Transformation of Psychiatric Care in Canada by Erika Dyck, Alex Deighton Ian Dowbiggin Erika Dyck and Alex Deighton. Managing Madness: Weyburn Mental Hospital and the Transformation of Psychiatric Care in Canada. Winnipeg: University of Manitoba Press, 2018. xiv + 321 pp. Ill. $31.95 (978–0–88755–795–8). On December 29, 1921, a crowd gathered in the city of Weyburn, in the Canadian province of Saskatchewan, to celebrate the opening of the province’s second mental hospital. In Managing Madness historians Erika Dyck and Alex Deighton tell the story of twentieth-century mental health care in Canada through the prism of the Weyburn hospital. Whereas most asylums erected in the 1800s had already become warehouses of insanity by the 1920s, Weyburn recapitulated that century-long history within a few short years, and by the 1940s, “had the rather unenviable distinction of having the highest number of deaths in mental hospitals in relation to population for the whole country” (p. 88). Little wonder that Canadian sociologist Erving Goffman coined the phrase “total institution” after studying Weyburn’s living conditions. Nonetheless, Weyburn was not just any mental hospital, nor was Saskatchewan just any political jurisdiction delivering mental health services in the twentieth century. Throughout the 1900s, Weyburn and Saskatchewan were also the sites of several cutting-edge reforms in mental health care. Weyburn “gained international recognition for making the most significant changes to mental health care on the continent” (p. 224). Most of the new treatments of the time—electroconvulsive therapy (ECT), insulin shock, lobotomy, and chlorpromazine—were used to one extent or another on Weyburn’s wards. Additionally, in the 1950s and 1960s, “the institution went through the most rapid, and arguably the most successful, down-sizing of a large mental hospital in the Western world” (p. 233). But in hindsight, it was Saskatchewan’s experiment with psychedelic research and treatment that stands out. Psychiatrists Humphry Osmond (who coined the word “psychedelic”) and Abram Hoffer spearheaded testing of lysergic acid diethylamide (LSD) on themselves and patients. Dyck and Deighton are not exaggerating when they say that Saskatchewan researchers “contributed significantly to international developments” in mental health. The province’s “daring experimentation” in both general and mental health put Saskatchewan squarely on the psychiatric map (pp. 115–16). Much of this psychiatric history played out against the backdrop of the election in 1944 of a Cooperative Commonwealth Federation (CCF) government [End Page 716] under Thomas (Tommy) Clement Douglas. The CCF government, inspired by Douglas’s faith in scientific expertise and Social Gospel Christianity, proceeded to introduce North America’s first state-funded program of health services as well as an integrated health care system that combined reform along general and mental health lines. The trailblazing Douglas was willing to invest government funding in mental health treatment and research. The result was that, in the 1950s, Weyburn went from being one of the worst asylums in the world to enjoying the “status of a world-class institution” (p. 116). Managing Madness contains fascinating glimpses into Saskatchewan’s psychiatric past. For example, architect Kiyoshi Izumi, on whose designs the Yorkton Psychiatric Centre was partly based, liked to wander the wards at Weyburn high on LSD in an attempt to visualize the hospital’s interiors as patients did (p. 110). In August 1967, a discharged psychiatric patient killed nine family members at a farm near Shell Lake, Saskatchewan. It was the biggest single mass murder in Canadian history until 1989, when a gunman murdered fourteen women at Montréal’s École polytechnique. The “Shell Lake Massacre” sparked a nationwide backlash against the policy of deinstitutionalization, which had been unfolding since the 1950s. Dyck and Deighton conclude that Weyburn was neither a “total institution” nor the monument to suffering humanity its supporters claimed it was in its beginnings. The mental hospital was a “blunt instrument,” they write, “for managing extremely subtle and complicated sets of problems, only some of which were clinical.” Their thesis is that involving “consumers” in “meaningful decision-making roles” when it comes to planning mental health policy might lead to “a more nimble system.” That may in fact be a “first step” toward...

This study aimed to investigate the prevalence and types of Complementary and Alternative Medicine (CAM) utilization among Iranian patients referred to psychiatric clinics with self-reported insomnia. It also sought to explore demographic characteristics, attitude of the patients to CAM, the factors influencing patients' decision to use CAM, and factors thought to be linked to the adoption of CAM in this patient population. A cross-sectional study was conducted between July 2023 and October 2023 on 217 patients at outpatient academic psychiatric clinics affiliated with Shiraz University of Medical Sciences. Data was collected using the Persian version of the international questionnaire to measure use of complementary and alternative medicine (I-CAM-IR), assessing CAM usage, motives, specific modalities, and sources of exposure. Descriptive statistics were employed to analyze demographic characteristics, while Chi-square tests and logistic regression analyses were used to assess associations between demographic factors and CAM usage. A total of 217 patients were initially recruited for the study; however, 12 participants were excluded due to incomplete or invalid data, resulting in a final sample of 205 participants included in the analysis. Of 205 participants, 68.3% reported CAM use, with herbal medicines (73.6%), Persian medicine (45.7%), vitamins and minerals (43.6%), and cupping (10.7%) being prominent modalities. Significant associations were observed between CAM use and demographic factors such as age (P = 0.006), gender (P < 0.001), education (P = 0.006), occupation (P = 0.002), father and mother education levels (P < 0.001, P = 0.015), and family income (P = 0.019). Most CAM users (78.1%) did not inform healthcare providers about their CAM use, with perceived effectiveness mainly focused on health promotion (80.6%). This study reveals a substantial prevalence of CAM utilization among insomnia patients in psychiatric clinics of Iran, with demographic factors influencing CAM use. Healthcare providers should consider incorporating discussions about CAM into insomnia management strategies and be prepared to address patient preferences for complementary treatments. Future research should further explore the impact and outcomes of CAM utilization in managing insomnia to optimize patient care in psychiatric settings.

Among the most contentious legal and ethical issues concerning the use of electroconvulsive therapy (ECT) are the criteria for obtaining a valid consent to treatment and its administration to involuntarily hospitalized patients, with or without consent. This paper reviews the consent process, in particular the assessment of competence, as it is affected by the symptoms and clinical circumstances, including civil status, of those patients for whom ECT is prescribed. The ECT caseload at one psychiatric facility was reviewed to determine the diagnosis and civil status of each patient and the source of consent for each course of ECT prescribed over a 10-year period. Significant differences were found in the diagnostic distribution and the source of consent by diagnostic group between the 1,042 courses administered to informal patients and the 249 courses to involuntary patients. The results are discussed in the context of relevant Ontario legislation and hospital policies. Recommendations are made for the improvement of procedural safeguards to protect the autonomy of all patients.

SUMMARY Introduction: Psychogenic non-epileptic seizures (PNES) are part of the category of functional neurological symptom disorders, and currently, there is no consensus in the literature on the treatment of this pathology. This is a case report in which we present electroconvulsive therapy (ECT) as a possible treatment for the control of PNES and treatment-resistant depression (TRD) in a patient hospitalized in a psychiatric unit. Case report: M.A., female, 38 years old, white, single, diagnosed with PNES and TRD. After the failure of conventional psychiatric treatments and worsening of TRD due to new suicide attempts, ECT was chosen. Twelve sessions of ECT were performed in the treatment. Discussion: To monitor the patient's progress during ECT, four mental health assessment tools were used: section C of the Mini International Neuropsychiatric Interview (MINI)- Suicidal Risk, the Patient Health Questionnaire (PHQ-9), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Hamilton Depression Rating Scale (HAM-D-17). There was a significant overall clinical improvement in the depression instruments, evaluated by PHQ-9 (pre: 26/post 11), MADRS (pre: 54/post 28), and HAM-D-17 (pre: 39/post 13), and a decrease in suicide risk, according to the MINI (pre: 33/post: 12). Conclusion: The patient had a favorable outcome, surprising not only with the rapid improvement of the overall clinical condition but also with the absence of PNES after the completion of the twelve sessions of electroconvulsive therapy.