Electroconvulsive Therapy and Cochlear Implantation

Cochlear implant manufacturers currently contraindicate the use of electroconvulsive therapy (ECT) in CI users, citing theoretical evidence of potential harm to the patient or the implant despite a lack of clinical data. We report two uncomplicated cases of ECT in CI users, including the first reported case of bilateral ECT in a patient with bilateral CIs. The first case involves a 66-year-old visually impaired male with bilateral CIs. He suffered from major depressive disorder complicated by refusal of oral intake despite maximal pharmacological therapy. He underwent 9 consecutive cycles of bilateral ECT, after which his psychiatric condition improved. Cochlear implant function remained unchanged following the procedure. The second case involved a 65-year-old female with a left-sided CI and a history of recurrent depressive disorder. Her condition deteriorated with the onset of auditory hallucinations and increased suicidality. She underwent 8 consecutive cycles of unilateral ECT with right-sided electrode placement. Her psychiatric condition improved, and there was no change in CI impedance following the procedure. We report 2 successful cases of ECT in CI users, including the first reported case of bilateral ECT in a patient with bilateral cochlear implants. Further investigation into the safety of ECT in CI users is warranted to ensure that this crucial treatment modality remains available to this vulnerable patient cohort.

There is evidence that addition of pindolol, a beta-adrenergic/5-hydroxytryptamine-1A antagonist, can accelerate the onset of action of antidepressant medications. The purpose of this study was to determine whether pindolol administration can induce a rapid improvement in depressive symptoms in patients receiving electroconvulsive therapy (ECT) within six ECT treatments. A total of 20 patients with DSM-IV-diagnosed major depression who were undergoing a course of ECT as the clinically indicated treatment were recruited. They were neuroleptic, lithium, and antidepressant free for at least 1 week before the study. Of the 20 patients, 9 patients had been randomly assigned to receive pindolol 2.5 mg three times daily, and 11 patients received identical placebo three times daily for the duration of the first 6 ECT treatments. One of 9 patients in the pindolol group and 4 of 11 patients in the placebo group dropped out of the study. Using an outcome measure of a score < or =12 on the 29-item Hamilton Rating Scale for Depression (HAM-D), the authors found that four (50%) of eight patients responded to the combination treatment of ECT and pindolol within six ECT treatments. In contrast, none (0%) of seven patients who received placebo responded to ECT treatment. Furthermore, both mean 29-item HAM-D and Clinical Global Impression Scale scores after the sixth ECT treatment were significantly lower in patients treated with pindolol compared with those treated with placebo. However, the number of total ECT treatments within a course or the overall efficacy of ECT treatment was not altered by the addition of pindolol. The results of this study suggest that within six ECT treatments, pindolol administration hastens antidepressant effects of ECT in some depressed patients.

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.

Electroconvulsive therapy in depressed older adults with unrepaired abdominal aortic aneurysm: Safety first!

Little is known regarding the safety of electroconvulsive therapy (ECT) in the presence of cranial metallic objects (cMO) such as medical devices or metallic foreign bodies. The presence of cMO raises 3 theoretical concerns toward the safety of ECT: (1) cMO may significantly alter the ECT-induced electric field distribution in the brain regarding field strength and focality, (2) vascular complications at the location of the cMO due to the ECT-induced hyperdynamic state may occur, and (3) possible development of a prolonged seizure/status epilepticus during ECT as a consequence of a device-induced symptomatic epilepsy. In the light of missing systematic approaches, we intended to assess the safety of ECT in the presence of cMO with particular regard to the concerns as specified previously. A systematic review of previously published cases of ECT in patients with cMO was conducted. We identified 23 publications reporting 24 cases of ECT in the presence of cMO (cerebral clipping systems, 8 cases; cerebral coils, 2 cases; deep brain stimulator, 4 cases; osteosynthesis materials or other metallic medical devices, 7 cases; foreign bodies, 3 cases). Modified placement of ECT-electrodes was reported in 10 cases (42%). No ECT-related complications with regard to the proposed theoretical concerns were reported. The absence of cMO-related complications during ECT in the reported cases implies that cMO might not represent an absolute contraindication for the performance of ECT. However, the indication for ECT should be put in place thoroughly in patients with cMO. Further research is necessary for an adequate safety assessment.

BackgroundAgitation poses a significant challenge in the treatment of schizophrenia. Electroconvulsive therapy (ECT) is a fast, effective and safe treatment for a variety of psychiatric disorders, but no meta-analysis of ECT treatment for agitation in schizophrenia has yet been reported.AimsTo systematically evaluate the efficacy and safety of ECT alone or ECT-antipsychotics (APs) combination for agitation in schizophrenia.MethodsSystematic literature search of randomized controlled trials (RCTs) was performed. Two independent evaluators selected studies, extracted data about outcomes and safety with available data, conducted quality assessment and data synthesis. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) was used to judge the level of the overall evidence of main outcomes.ResultsSeven RCTs from China, including ECT alone (4 RCTs with 5 treatment arms, n=240) and ECT-APs combination (3 RCTs, n=240), were identified. Participants in the studies were on average 34.3(4.5) years of age and lasted an average of 4.3(3.1) weeks of treatment duration. All 7 RCTs were non-blinded, and were rated as low quality based on Jadad scale. Meta-analysis of the pooled sample found no significant difference in the improvement of the agitation sub-score of the Positive and Negative Syndrome Scale (PANSS) when ECT alone (weighted mean difference=-0.90, (95% confidence interval (CI): -2.91, 1.11), p=0.38) or ECT-APs combination (WMD=-1.34, (95%CI: -4.07, 1.39), p=0.33) compared with APs monotherapy. However, ECT alone was superior to APs monotherapy regarding PANSS total score (WMD=-7.13, I2=0%, p=0.004) and its excitement sub-score (WMD=-1.97, p<0.0001) as well as the PANSS total score at 14 days (WMD=-7.13, I2=0%, p=0.004) and its excitement sub-score at 7 and 14 days (WMD=-1.97 to -1.92, p=0.002 to 0.0001) after ECT. The ECT-APs combination was superior to APs monotherapy with respect to the PANSS total score at treatment endpoint (WMD=-10.40, p=0.03) and 7 days (WMD=-5.01, p=0.02). Headache (number-needed-to-harm (NNH)=3, 95%CI=2-4) was more frequent in the ECT alone group compared to AP monotherapy. According to the GRADE approach, the evidence levels of main outcomes were rated as ‘‘very low’’ (37.5%) and “low” (50%).ConclusionPooling of the data based on 7 RCTs from China found no advantage of ECT alone or ECT-APs combination in the treatment of agitation related outcomes in schizophrenia patients. However, ECT alone or ECT-APs combination were associated with significant reduction in the PANSS total score. High-quality RCTs are needed to confirm the current interpretations.

Electroconvulsive therapy (ECT) remains an effective treatment for major depressive disorder. Since 1995, Texas has maintained an ECT database including patient diagnoses and outcomes, and reporting any deaths within 14 days of receiving an ECT treatment, encompassing a total of 166,711 ECT treatments administered in Texas over the previously unreported period of 1998 to 2013. Descriptive analysis summarized information on deaths reported during the 16-year period-cause of death, type of treatment (index or maintenance) and patient demographics. Multiple logistic regression of death incidence by treatment session was performed to determine whether patient age, sex, race, diagnosis, or year of treatment was associated with death after ECT. Of those deaths occurring within 1 day of an ECT treatment, the death rate was 2.4 per 100,000 treatments. Looking at all deaths within 14 days of an ECT treatment, the death rate increased to 18 per 100,000 treatments but included all deaths regardless of likelihood of causal association with ECT, for example, accidents and suicides, the latter a leading cause of death among individuals with severe major depression or other disorders for which ECT is indicated. Death rate increased significantly with increasing patient age (P = 0.001) and male sex (P = 0.009), and there was a nonsignificant trend toward increased death amongst patients with bipolar disorder or schizophrenia (P = 0.058) versus depression. Our data indicate that ECT is in general a safe procedure with respect to the likelihood of immediate death. Suicide remains a significant risk in ECT patients, despite evidence that ECT reduces suicidal ideation.

BackgroundThere is a robust empirical evidence base supporting the acute efficacy of electroconvulsive therapy (ECT) for severe and treatment resistant depression. However, a major limitation, probably contributing to its declining use, is that ECT is associated with impairment in cognition, notably in anterograde and retrograde memory and executive function. Preclinical and preliminary human data suggests that ketamine, used either as the sole anaesthetic agent or in addition to other anaesthetics, may reduce or prevent cognitive impairment following ECT. A putative hypothesis is that ketamine, through antagonising glutamate receptors, protects from excess excitatory neurotransmitter stimulation during ECT. The primary aim of the ketamine-ECT study is to investigate whether adjunctive ketamine can attenuate the cognitive impairment caused by ECT. Its secondary aim is to examine if ketamine increases the speed of clinical improvement with ECT.Methods/DesignThe ketamine ECT study is a multi-site randomised, placebo-controlled, double blind trial. It was originally planned to recruit 160 moderately to severely depressed patients who had been clinically prescribed ECT. This recruitment target was subsequently revised to 100 patients due to recruitment difficulties. Patients will be randomly allocated on a 1:1 basis to receive either adjunctive ketamine or saline in addition to standard anaesthesia for ECT. The primary neuropsychological outcome measure is anterograde verbal memory (Hopkins Verbal Learning Test-Revised delayed recall task) after 4 ECT treatments. Secondary cognitive outcomes include verbal fluency, autobiographical memory, visuospatial memory and digit span. Efficacy is assessed using observer and self-report efficacy measures of depressive symptomatology. The effects of ECT and ketamine on cortical activity during cognitive tasks will be studied in a sub-sample using functional near-infrared spectroscopy (fNIRS).DiscussionThe ketamine-ECT study aims to establish whether or not adjunctive ketamine used together with standard anaesthesia for ECT will significantly reduce the adverse cognitive effects observed after ECT. Potential efficacy benefits of increased speed of symptom improvement and a reduction in the number of ECT treatments required will also be assessed, as will safety and tolerability of adjunctive ketamine. This study will provide important evidence as to whether adjunctive ketamine is routinely indicated for ECT given for depression in routine NHS clinical practice.Trial RegistrationCurrent Controlled Trials: ISRCTN14689382 (assigned 30/07/2012); EudraCT Number: 2011-005476-41

Background and Objective: Electroconvulsive therapy (ECT) is the end choice treatment for patients with major depressive disorder (MDD). Regarding researches that show NMDA receptor inactivation could yield the same results as anti-depressant drugs, however, the present study examined co-administration of ECT and ketamine (as NMDA antagonist) on depressed rat behaviors. Materials and Methods: Fifty healthy adult male Wistar rats were divided into control (normal, no treatment) and CUMS induced depressed rats. The depressed animals were subdivided into 1- ECT, 2-ketamine, and 3- ECT + ketamine and 4- no treatment. We used sucrose preference, forced swimming, open field and elevated plus maze tests for evaluation of depression-related behavioral function. Results: Data analysis in CUMS depressed rats that treated with ketamine + ECT showed higher sucrose consumption in sucrose preference test, more immobility in forced swimming, and the vast activity in open field and plus maze tests. Conclusion: The behavioral analysis tests show that combination therapy with ketamine and electroconvulsive could markedly reduce depression and anxiolytic behaviors than ketamine or ECT treatment alone.

WHAT IS KNOWN ON THE SUBJECT?: ECT is a fast-working and potentially life-saving treatment, but it is still considered a controversial treatment choice. Due to lack of knowledge and public stigma, ECT can be an anxiety-inducing treatment for people experiencing severe depression. The nurse's role is to alleviate this anxiety, aid recovery and minimize the risk of relapse. They manage this onerous task ideally through the therapeutic relationship, and use the skills of assessment and risk identification in order to maximize patient outcomes. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The views of mental health nurses who provide care for adults receiving treatment of ECT for severe depressive illness are in the main positive. The knowledge of and attitude towards ECT among nurses may reflect on patients and influence treatment choice. If stigma is not addressed, then patients will not be appropriately informed regarding their treatment options. Mental health nurses need to engage in reflective practice to ensure that the dignity of the patient is maintained throughout this treatment. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental Health nurses should engage with additional training, formalized clinical supervision and avail of peer support in order to improve confidence, skills and quality of care in the delivery of ECT. Education modules should include a presentation of evidence of effectiveness of ECT as a treatment option. Dialogue among mental healthcare colleagues is important about caring for people presenting for ECT treatment. This will ensure that the mental health nurse can remain cognizant of the potential for patient distress throughout this treatment. ABSTRACT: Background There is a considerable dearth of literature on attitudes towards Electroconvulsive Therapy (ECT) as a treatment for severe depression. Despite being a highly effective treatment, it is still stigmatized even among professionals. Understanding perceptions and knowledge related to ECT treatment among healthcare providers is important for ensuring that treatment can be safely explored as a treatment option with patients. Aim The overall aim of this study is to explore the views of mental health nurses who provide nursing care to people receiving ECT for severe depressive illness in a mental health setting. Methods This is a qualitative study using focus groups (n=2) with 14 mental health nurses who had a minimum of 3months experience caring for older adults receiving ECT. Transcripts were subjected to a thematic analysis. Full ethical approval was granted for this study. Results In total, four themes were identified exploring attitudinal changes, managing patient dignity, reflecting changes in practice and managing the unknown. In general, participants experienced ECT as a positive treatment option for adults with severe depressive illness contributing to an enhanced quality of life. Conclusion Findings indicate a desire to improve person-centred care for patients undergoing ECT. Educational support for nurses who work in this area would improve confidence on work practices and lead to improved patient experience. Mental health personnel without direct experience of the treatment should be exposed to educational modules to decrease stigma and to best facilitate informed decision-making among the patient cohort.

To determine event rates for specific medical events and mortality among individuals receiving electroconvulsive therapy (ECT). Population-based cohort study using health administrative data of acute ECT treatments delivered in Ontario, Canada, from 2003 to 2011. We measured the following medical event rates, per 10000 ECT treatments, up to 7 and 30days post-treatment: stroke, seizure, acute myocardial infarction, arrhythmia, pneumonia, pulmonary embolus, deep vein thrombosis, gastrointestinal bleeding, falls, hip fracture, and mortality. A total of 135831 ECT treatments were delivered to 8810 unique patients. Overall medical event rates were 9.1 and 16.8 per 10000 ECT treatments respectively. The most common medical events were falls (2.7 and 5.5 per 10000 ECT treatments) and pneumonia (1.8 and 3.8 per 10000 ECT treatments). Fewer than six deaths occurred on the day of an ECT treatment. This corresponded to a mortality rate of less than 0.4 per 10000 treatments. Deaths within 7 and 30days of an ECT treatment, excluding deaths due to external causes (e.g., accidental and intentional causes of death), were 1.0 and 2.4 per 10000 ECT treatments respectively. Morbidity and mortality events after ECT treatments were relatively low, supporting ECT as a low-risk medical procedure.

Taurine and glutathione levels in plasma before and after ECT treatment

SummaryBackgroundThe use of electroconvulsive therapy (ECT) is limited by concerns about its cognitive adverse effects. Preliminary evidence suggests that administering the glutamate antagonist ketamine with ECT might alleviate cognitive adverse effects and accelerate symptomatic improvement; we tested this in a randomised trial of low-dose ketamine.MethodsIn this multicentre, randomised, parallel-group study in 11 ECT suites serving inpatient and outpatient care settings in seven National Health Service trusts in the North of England, we recruited severely depressed patients, who were diagnosed as having unipolar or bipolar depressive episodes defined as moderate or severe by DSM-IV criteria, aged at least 18 years, and were able and willing to provide written consent to participate in the study. Patients were randomly assigned (1:1) to ketamine (0·5 mg/kg intravenous bolus) or saline adjunctive to the anaesthetic for the duration of their ECT course. Patients and assessment and ECT treatment teams were masked to treatment allocation, although anaesthetists administering the study medication were not. We analysed the primary outcome, Hopkins Verbal Learning Test-Revised delayed verbal recall (HVLT-R-DR) after four ECT treatments, using a Gaussian repeated measures model in all patients receiving the first ECT treatment. In the same population, safety was assessed by adverse effect monitoring. This trial was registered with International Standard Randomised Controlled Trial Number, number ISRCTN14689382.FindingsBetween early December, 2012, and mid-June, 2015, 628 patients were screened for eligibility, of whom 79 were randomly assigned to treatment (40 in the ketamine group vs 39 in the saline group). Ketamine (mean 5·17, SD 2·92), when compared with saline (5·54, 3·42), had no benefit on the primary outcome (HVLT-R-DR; difference in means −0·43 [95% CI −1·73 to 0·87]). 15 (45%) of 33 ketamine-treated patients compared with 10 (27%) of 37 patients receiving saline experienced at least one adverse event which included two (6%) of 33 patients who had ketamine-attributable transient psychological effects. Psychiatric adverse events were the most common in both groups (six [27%] of 22 adverse events in the ketamine group vs seven [54%] of 13 in the saline group).InterpretationNo evidence of benefit for ketamine was found although the sample size used was small; however, the results excluded greater than a small to moderate benefit with 95% confidence. The results do not support the use of adjunctive low-dose ketamine in routine ECT treatment.FundingNational Institute for Health Research (NIHR) Efficacy and Mechanism Evaluation (EME) programme, an MRC and NIHR partnership.

To retrospectively analyse patients receiving maintenance Electroconvulsive therapy (ECT), patterns of ECT treatment administration and impact on hospitalisation before and during treatment, in a single New Zealand District Health Board catchment. We also asked other District Health Boards in New Zealand for annual data on their use of maintenance ECT. Regional analysis: retrospective analysis of patient-level data over 9 years. National analysis: survey of maintenance ECT/year. Regionally, 14 patients received maintenance ECT over 9 years. Patients were 50% male, with mean age 59 years, and principal diagnoses included schizophrenia, bipolar disorder and major depressive disorder. The time between ECT treatments tended to be shorter for patients with schizophrenia compared with those with mood disorders. Duration of time in hospital during maintenance ECT, compared with pre-ECT, was reduced by 52% for all patients, with greater reductions for patients with mood disorders compared with those with schizophrenia. Nationally, 19.7% of all ECT treatments in New Zealand (range 4-57%) were for maintenance treatment. Regional and national use patterns of maintenance ECT in New Zealand resemble those reported internationally. The RANZCP section of neurostimulation is planning ECT standards which would assist with ensuring coherence and quality of High-dose contrast-enhanced computed tomography/modified electroconvulsive therapy practice in New Zealand.

IntroductionTranylcypromine (TCP), an irreversible monoamine oxidase inhibitor (MAOI), is recommended for difficult-to-treat depression. Besides the requirement of a low-tyramine diet, there are concerns about the safety of TCP treatment during anaesthesia and electroconvulsive therapy (ECT). For safety reasons, many psychiatrists prefer to terminate TCP before ECT.ObjectivesTo assess the safety of tranylcypromine treatment during ECT series in patients with difficult-to-treat depression (DTD).MethodsIn this retrospective study we report on n=19 patients, who were treated with tranylcypromine during the ECT series. ECT parameters, clinical and safety data were obtained from our clinical database.ResultsMean age of patients was 51 years (range 29-77) at time of the first ECT sessions. 58 % (n=11) of patients were female. In total, 198 ECT sessions were analysed (mean 11, median 9,5 per patient). Mean TCP dose was 44 mg at time of first ECT (median 43). Concomitant TCP and ECT treatments were well tolerated during the entire ECT series. In one case TCP treatment was discontinued due to self-limiting bigeminus during the ECT session. In another case TCP and other drugs as well as the ECT series were stopped after the patient developed delirium. At the end of ECT series the mean TCP dosage was 37 mg.ConclusionsTranylcypromine appears to be safe during ECT series and does not necessarily have to be terminated prior to electroconvulsive therapy.DisclosureNo significant relationships.