Electroconvulsive Therapy in Sweden 2013

ELECTROCONVULSIVE THERAPY (ECT) IS ONE OF THE most controversial treatments in all of medicine. There are a number of reasons for this. The discovery in the 1930s that inducing a series of generalized seizures, initially with chemicals, later with electric current, could cause the recovery of patients with severe and previously untreatable mental disorders produced a wave of enthusiasm that eventually led to a period of indiscriminate use and misuse in the middle decades of the 20th century. This period of abuse created, perhaps deservedly at that time, a bad reputation for an effective treatment modality. That reputation was enhanced by the immediate adverse effects of bitten tongues and even fractured bones and teeth caused by the induction of generalized seizures, and the painful effects of electroshocks administered without anesthesia when they did not successfully induce a seizure with loss of consciousness. The 1975 movie One Flew Over the Cuckoo’s Nest contributed to an erroneous view of ECT as a punitive, painful, and assaultive procedure used by authorities to control inconvenient creativity. That view has been associated with attempts to regulate, or even eliminate, the use of ECT through legislation in a number of jurisdictions, and public fears and distrust about the use of ECT have persisted. The best response to such concerns on the part of physicians is to be aware of the facts about current use of ECT, including its efficacy and possible adverse effects, so they can respond to questions from patients, families, and the public. The indications, possible adverse effects, and current recommendations for treatment procedures have been summarized in a task force report just published by the American Psychiatric Association Committee on Electroconvulsive Therapy. An effective and safe treatment for severe major depression, ECT has had response rates reported in the range of 80% to 90% as a first-line treatment, and in the range of 50% to 60% for patients who have not responded to 1 or more trials of treatment with antidepressant drugs. Electroconvulsive therapy may also be seriously considered as treatment for patients with acute mania, and for patients with schizophrenia who have not responded to adequate trials of antipsychotic medications. As currently practiced, ECT involves the use of informed consent, ultra-brief general anesthesia and muscle relaxants (thus attenuating motor seizure activity) with appropriate airway management, and use of ECT devices to provide adequate ictal responses. Most patients in the United States receive 3 treatments per week, and a course of ECT for major depression generally consists of 6 to 12 treatments, with the course ended or tapered as soon as maximum response has been reached. This usually occurs more quickly than the 4 to 6 weeks required for an adequate trial of an antidepressant drug. There continues to be some controversy about the use of right unilateral or bilateral electrode placement, with right unilateral ECT causing less cognitive adverse effects, but bilateral ECT often viewed as being more effective. A recent randomized controlled trial showed that right unilateral ECT at high dosage was as effective as bilateral ECT in many patients and caused less impairment on several measures of anterograde and retrograde memory. The issue of cognitive adverse effects from ECT is central to its reputation for harm and requires careful consideration to separate facts from myths. Studies of this issue have been reviewed and summarized by the American Psychiatric Association Committee on Electroconvulsive Therapy. Patients experience a variable but usually brief period of disorientation (postictal confusion) immediately after seizure induction. Electroconvulsive therapy also typically results in retrograde amnesia, greatest immediately after the course of treatment and for events that occurred temporally close to the treatment. The extent of the retrograde amnesia usually decreases substantially with time, but many patients have persistent loss of memory for some events that occurred in the interval starting several months before and extending to several weeks after their ECT course. Anterograde amnesia, characterized by rapid forgetting of learned information, also may occur during and immediately following ECT but resolves within a few weeks. Importantly, there is no objective evidence that ECT has any long-term effect on the capacity to learn and retain new information. Assessment of cognitive effects from ECT is complicated by the cognitive impairments associated with the mental disorders being treated. For example, patients with severe depression may have substantial impairments in cognitive function, and patients with schizophrenia or other psychotic

Byline: B. Gangadhar In the recently introduced Mental Health Care bill, electroconvulsive therapy (ECT) practice figures with a caution. The bill allows the use of ECT only under anesthesia (modification). In other words, if the bill is passed and implemented, the unmodified (direct) ECT cannot be practiced. Concerns have been raised by some well-meaning psychiatrist colleagues. The cost of ECT would increase, thus taxing the poor patients. Anesthesiologists to provide modification are fewer. In emergency ECT situations, depending on anesthesiologists would pose challenges in that crucial eleventh hour. The position in the bill and the arguments for or against the unmodified ECT are examples of the issues to be faced by psychiatrists in the days to come. How are we prepared? In its first move, the Indian Psychiatric Society produced the position paper on unmodified ECT. [sup][1] It did endorse the benefits of modification in ECT and also conceded that such a procedure should be the contemporary standard. At the same time, the group recorded the concerns of denying ECT on the grounds of unavailability of resources to support modification. The position of the society is to allow use of unmodified ECT only in exceptional circumstances. Unmodified ECT has been a matter of concern and debate since many years. As early as in 1980, Lancet published several views for and against following a report of use of unmodified ECT in Broadmoor (UK). Arguing for unmodified ECT, Crammer [sup][2] also stated that some patients actually preferred ECT without injections (unmodified). Another supporter of this procedure stated that withholding ECT when modification is not possible amounts to unethical practice. Situations of failing to get a vein for intravenous injections (repeated injections in previous ECT sessions can result in such a difficulty) is one such circumstance when unmodified ECT may be the option. [sup][3] On the other hand, nearly 40 other psychiatrists wrote against unmodified ECT, terming it as anachronistic and indefensible. [sup][4] They also opined that unavailability of anesthesiologist does not condone use of unmodified ECT. It may be noted that some psychiatry textbooks from the West have altogether dropped information on unmodified ECT in their recent editions. There is no doubt that modified ECT should remain the current standard of ECT practice. In reality, however, unmodified ECT is in vogue in many parts of the world, [sup][5] China, [sup][6] Pakistan, [sup][7] and India. [sup][8] Together, this would account for the largest ECT population in the world. In our country itself, a recent survey indicated that over 50% of ECTs are unmodified. [sup][9] Clearly, the bill would affect the majority in this regard. This majority would, therefore, not get the benefits of ECT as unmodified ECT would be disallowed. Even if supported by the position adopted by the Indian Psychiatric Society, most, barring the exceptional ones, would be denied ECT. Psychiatrists may also be tempted to adopt different definitions of this exceptional indication. For example, a social reason was an urgent indication for ECT. [sup][10] It is true that earlier users of unmodified ECT had recognized adverse events such as fractures and even rupture of bladder, [sup][11] apart from others, that discouraged them from using unmodified ECT. In this context, Indian reports have reassured, though not convincingly, that unmodified ECT is not as unsafe as has been projected. [sup][12],[13] Benzodiazepine as a muscle relaxant has been suggested as an alternative to modification. [sup][14],[15] It is arguable, however, as an anticonvulsant this drug may interfere with seizure induction. Suggestions have also been advanced if psychiatrists can be trained in ECT-related anesthesia procedures. [sup][16] This issue surely deserves consideration for debate and consensus. In this background, we need to be also alert to the concerns of patients and their kin. …

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

There are wide global variations in electroconvulsive therapy (ECT) use patterns. This audit reviewed patient-level ECT use patterns over 10 years at a single New Zealand clinic, including factors associated with clinical response and patterns of repeated administration. Retrospective audit of all 2003-2012 ECT and clinical file data. A total of 199 patients received ECT, which was used to treat mostly affective disorders in a predominantly female, older population, generally with a single course of treatment. There were different demographics and patterns of ECT use between patients being treated for affective and psychotic disorders. Overall treatment response was high, with over 90% of patients having a full or partial response. Treatment response was not associated with diagnosis, gender, or medication use, but showed a trend in significance for greater response in elderly patients. ECT use patterns in Otago New Zealand are similar to those reported in Australia, USA, and UK, although yearly use rate in Otago is lower. Because of their different demographic and ECT treatment patterns, future studies should report data for patients with affective and psychotic disorders separately.

Electro-convulsive therapy (ECT) remains an important, potentially life-saving tool in the treatment of depression. Its efficacy in depression is second to none, yet it remains underused by psychiatrists. It is a very safe treatment, safer than antidepressants in some patients. Adverse effects, particularly memory impairment, are increasingly better managed with improved treatment parameters, such as the use of high-dose unilateral ECT. National guidelines support the use of ECT, although not as robustly as the Royal College of Psychiatrists, which recommends earlier consideration and use of ECT than is currently the case. ECT was the first neuromodulation treatment for depression. Several others have since been developed, supported by a variable degree and quality of evidence.

This Doctor of Medicine thesis is based on a series of seven published papers examining aspects of electroconvulsive therapy (ECT) that are of interest to old age psychiatrists. Review Papers. Two review papers are included. The first is a systematic review and meta-analysis of bifrontal ECT for depression. Bifrontal electrode placement was developed as a potentially cognitive-sparing alternative to more conventional electrode placements. Our findings suggested that the advantage of bifrontal ECT may lie in a more favourable benefit to cognitive risk profile than both bitemporal and high-dose right unilateral ECT, rather than in its absolute efficacy. Our in-depth review of the role of ictal electroencephalographic (EEG) indices in ECT practice addressed the objective of optimising ECT treatment technique as a means of improving its risk-benefit profile. Our findings suggested that measures of seizure intensity, consistency of EEG pattern over time and postictal suppression can be appraised alongside clinical findings to guide ECT administration. Epidemiological Studies. Our two original epidemiological studies examined ECT use in Victoria, Australia, from 1998 to 2007 based on analysis of statutory data from the Office of the Chief Psychiatrist of Victoria. There first provided an overview of ECT use in young (25-44 years), middle-aged (45-64 years) and older adults (65+ years) and graphically presented ten-year population-adjusted ECT utilisation rates. A higher utilisation rate among older adults was one key finding. The second paper reanalysed this data according to a ‘young-old’ (65-79 years) and ‘old-old’ (80+ years) age division to determine if this pattern was accentuated with increasing age. Age-adjustment of data revealed that old-old adults (women especially) had the highest rate of ECT use overall as well as for depression and public sector treatment. Our findings have clinical and service delivery implications, given the higher medical comorbidity and personal care needs of this population. Clinical Studies. The first of three original clinical research studies examined the rise in the stimulus dose required across a course of moderate-dose right unilateral ECT, as an indirect marker of treatment adequacy among older adults. Our finding that required treatment doses generally did not increase quickly, despite rising seizure thresholds across a treatment course, suggested that moderate-dose ECT cannot be dismissed as a treatment option simply because of the rate of change in electrical stimulation. The second paper examined the impact of ECT on tests of balance and gait, to increase understanding of the potential factors contributing to ECT-related falls in older adults. The absence of any deleterious effect of ECT on balance and gait led us to postulate that post-ECT confusion might actually be a key mediator of ECT-related falls. The final paper compared clinicodemographic characteristics of cognitive test completers and noncompleters from a prior study of the impact of ECT on the cognition of older adults, to determine the likelihood of the results of such studies being widely clinical applicable. Our findings suggested cognitive test nonparticipants to be more severely psychiatrically unwell than test participants, suggesting their exclusion might bias and clinically invalidate study results.

Recent studies on electroconvulsive therapy (ECT) have reported inconsistent frequencies of ECT use in various countries. Therefore, this study aimed to investigate the trends of ECT use in a large psychiatric center in China over 6 consecutive years. A total of 22,120 inpatients, aged 18-59 years, admitted during the period 2015-2020 to a large grade-A tertiary psychiatric center in Beijing were enrolled in this retrospective study. Demographic and clinical data including vital signs; daily living abilities(ADL); emergency referrals; psychiatric and physical prescriptions were collected from an electronic medical records system. In all, 2,213 (10.0%) inpatients received ECT, with an average number of sessions of 10.3 ± 6.6. There were no significant differences between the ECT and non-ECT groups in terms of educational level, marital status, length of hospital stay, and blood pressure. After using the propensity score matching (PSM) method, Multiple logistic regression analysis revealed that ECT use was independently associated with married/cohabitating (OR = 1.21, 95% CI: 1.03-1.43); few hospitalizations (OR = 0.96, 95% CI: 0.93-0.99); unemployed (OR = 1.43, 95% CI: 1.16-1.76); emergency referral (OR = 1.62, 95% CI: 1.36-1.93); increased use of antipsychotics (OR = 2.63, 95% CI: 1.88-3.68), mood stabilizers (OR = 1.30, 95% CI: 1.01-1.67), antidepressants (OR = 1.40, 95% CI: 1.13-1.73), and trihexyphenidyl (OR = 1.30, 95% CI: 1.05-1.50); reduced use of hypoglycemic drugs (OR = 0.64, 95% CI: 0.45-0.83); fast heart rate (OR = 1.01, 95% CI: 1.01-1.02); and severe impairments in ADL. Compared with that in 2015 (13.2%), ECT use decreased annually from 2016 (12.4%) to 2019 (9.6%), especially in 2020 (5.7%), given the impact of the COVID-19 pandemic in China. The ECT usage and year-by-year decrease in ECT use in this study were consistent with the recent trends in other regions. Patients with the married/cohabitating, unemployed, and emergency-referral, unstable vital signs, more severe disability received ECT for quick alleviation of their conditions.

The effects of electroconvulsive therapy are usually estimated from changes in depression scales from studies with relatively small patient samples. Larger patient samples can be achieved from epidemiological registers, which provide information on other social and clinical predictors, results and risks. To examine whether depression severity predicts the use of electroconvulsive therapy, risk of re-hospitalization, suicidal behaviour and mortality following electroconvulsive therapy in patients with major depression. A cohort of 92,895 patients diagnosed with single or recurrent depression between 2005 and 2016 in the Danish National Patient Registry was followed for electroconvulsive therapy and adverse outcomes. Associations between electroconvulsive therapy and outcomes were analysed using Cox regression. A total of 5004 (5.4%) patients were treated with electroconvulsive therapy. Depression severity was the strongest predictor of electroconvulsive therapy. Electroconvulsive therapy was used more frequently above age 70, in those better educated or married, whereas comorbid alcohol abuse or history of prior stroke at study entry were associated with lower rates. Electroconvulsive therapy was associated with lower mortality. The adjusted hazard ratio for the association between electroconvulsive therapy and suicide in patients with mild depression was 6.99 (3.30-14.43), whereas it was 1.10 (0.55-2.20) in those with severe depression and psychotic symptoms. A similar pattern was seen for emergency contacts and attempted suicide. Electroconvulsive therapy was associated with lower all-cause mortality and the relative risk for re-hospitalization and attempted and committed suicide was lowest in patients with the most severe depression. Electroconvulsive therapy is an important treatment, with significant public health benefits, for patients with severe depression.

Healthcare professionals have debated the use and effects of electroconvulsive therapy (ECT) for more than 65 years. Yet, knowledge about, and attitudes towards, ECT have not been thoroughly researched within the Australian community. This study focused on a Western Australian perspective on these issues. The objectives were achieved with specifically developed questionnaires. Six hundred surveys were distributed across the metropolitan area of Perth, Australia. A total of 379 completed questionnaires indicated that more than 60% of respondents had some knowledge about the main aspects of ECT. Participants were generally opposed to the use of ECT on individuals with psychosocial issues, on children and on involuntary patients. Public perceptions of ECT were also found to be mainly negative. The findings suggest that clinicians should ensure that individuals recommended for ECT are knowledgeable about basic ECT processes and implications in order to ensure their full informed consent.

Manic patients receiving ECT in a Brazilian sample

The first documented pediatric use of Electroconvulsive therapy (ECT) occurred in Europe in 1941. Since then, predominantly successful treatments and reasonable side effects have been reported in severely ill minors. Nevertheless, a shy reluctance determines the controversy about ECT in young patients. This study describes the use of ECT in children and adolescents in Europe. We systematically searched the literature concerning the practice of ECT in minors in all 53 European countries. In addition, we surveyed European experts about national practices and compared guidelines for ECT in minors. The search yielded 79 publications from 18 European countries, mainly from Western Europe, Israel, and Turkey. National data were available from eight countries. These showed an interestingly high relationship between the number of minors treated with ECT and the general use of ECT. No persistent deficits or deaths were reported. On the other hand, no randomized clinical trial was found, and many publications lacked relevant information. Accordingly, the appraisal of the evidence in the guidelines varies considerably. Experts from 13 European countries consistently reported infrequent and unsystematic use of ECT in minors. ECT has been used successfully in minors in Europe with reasonable complications and side effects. Adverse effects on the developing brain, as often suspected, have not been scientifically supported in eight decades. Nevertheless, the use of ECT in Europe is sparse and dependent on accidental circumstances. High-quality evidence is needed, as well as improved knowledge and training of child and adolescent psychiatrists.

Electroconvulsive therapy (ECT) has been reported to have efficacy in the treatment of depressive illness, mania and catatonia (U.K. ECT Review Group, 2003; National Institute for Clinical Excellence, 2003; Scott, 2004). The Royal College of Psychiatrists in the U.K. continues to support the use of ECT within the framework of its guidance on the use of ECT (Scott, 2004) and has developed an ECT accreditation service for clincal services that use ECT. In May 2003, the National Institute of Clinical Excellence (NICE) issued a technical appraisal on the use of ECT in England (NICE, 2003). This is essentially guidance on the use of ECT which clinicians are required to follow in their clinical practice.

ObjectiveElectroconvulsive therapy (ECT) is an important but underused treatment for severe psychiatric illnesses. We sought to examine the variability of ECT utilization at a population level and between several subgroups. We also sought to quantify the impact of the COVID-19 pandemic on ECT utilization.MethodsWe used population level data from Ontario to examine all ECT procedures administered from 1 January 2007 to 31 December 2023. Our primary measure of variability was the rate of ECT procedures per 1,000 population. We included three subgroups at time of ECT procedure: age (18-39, 40-64, and 65+), biologic sex (male/female), and Ontario Health (OH) region of residence (West, Central, Toronto, East, North West, North East). To quantify the impact of the COVID-19 pandemic we calculated the change in ECT rate from 2019 to 2020 (acute effect) and 2019 to 2023 (persistent effect).ResultsThere were 450,381 ECT procedures delivered during the observation period. The yearly rate of ECT increased from 1.69 per 1,000 in 2007 to a peak of 3.08 per 1,000 in 2019. In 2023 the greatest per capita rates of ECT use were in the 65+ age group, female sex, and North East geographic region. In 2023, the rates of ECT use in different geographic regions ranged from 1.28 (North West) to 4.19 per 1,000 (North East). The COVID-19 pandemic resulted in an immediate 26.73%, followed by a 17.47% persistent drop in the rate of ECT with notable regional heterogeneity.ConclusionsWhile ECT use increased over time, there were differences in this increase between age groups, biological sex, and geographic regions. The COVID-19 pandemic had significant immediate and persistent impacts on the rates of ECT use highlighting the need for ongoing population level monitoring of this important treatment.Plain Language Summary TitleElectroconvulsive therapy volume in Ontario from 2007 to 2023.

The articles in this debate address two separate but overlapping questions regarding the management of severe depression in older adults: (1) Is electroconvulsive therapy (ECT) an efficacious and safe treatment, and (2) What is the role of psychotherapy? That the first question is asked at all may come as a surprise to the many practitioners of geriatric psychiatry who consider ECT to be an indispensable part of their therapeutic tool kit. Yet, Wilkinson argues that the evidence supporting the efficacy of ECT in the elderly is “sparse” and derived from studies that are “of poor quality.” He provocatively states that psychotherapy “is at least as important as ECT” in the management of severe late-life depression, and advocates the more widespread use of psychotherapy to treat severe depression in older adults, including individuals admitted to psychiatric inpatient units. There are two issues here. First, what is severe depression? Second, what constitutes sufficient evidence to support the use of ECT or psychotherapy in severe depression in late life?

Electroconvulsive therapy (ECT) involves the induction of a seizure for therapeutic purposes by the administration of a variable frequency electrical stimulus shock via electrodes applied to the scalp. The effects of its use in people with schizophrenia are unclear. To determine whether electroconvulsive therapy (ECT) results in clinically meaningful benefit with regard to global improvement, hospitalisation, changes in mental state, behaviour and functioning for people with schizophrenia, and to determine whether variations in the practical administration of ECT influences outcome. We undertook electronic searches of Biological Abstracts (1982-1996), EMBASE (1980-1996), MEDLINE (1966-2004), PsycLIT (1974-1996),SCISEARCH (1996) and the Cochrane Schizophrenia Group's Register (July 2004). We also inspected the references of all identified studies and contacted relevant authors. We included all randomised controlled clinical trials that compared ECT with placebo, 'sham ECT', non-pharmacological interventions and antipsychotics and different schedules and methods of administration of ECT for people with schizophrenia, schizoaffective disorder or chronic mental disorder. Working independently, we selected and critically appraised studies, extracted data and analysed on an intention-to-treat basis. Where possible and appropriate we calculated risk ratios (RR) and their 95% confidence intervals (CI) with the number needed to treat (NNT). For continuous data Weighted Mean Differences (WMD) were calculated. We presented scale data for only those tools that had attained pre-specified levels of quality. We also undertook tests for heterogeneity and publication bias. This review includes 26 trials with 50 reports. When ECT is compared with placebo or sham ECT, more people improved in the real ECT group (n=392, 10 RCTs, RR 0.76 random CI 0.59 to 0.98, NNT 6 CI 4 to 12) and though data were heterogeneous (chi-square 17.49 df=9 P=0.04), its impact on variability of data was not substantial (I-squared 48.5%). There was a suggestion that ECT resulted in less relapses in the short term than sham ECT (n=47, 2 RCTs, RR fixed 0.26 CI 0.03 to 2.2), and a greater likelihood of being discharged from hospital (n=98, 1 RCT, RR fixed 0.59, CI 0.34 to 1.01). There is no evidence that this early advantage for ECT is maintained over the medium to long term. People treated with ECT did not drop out of treatment earlier than those treated with sham ECT (n=495, 14 RCTs, RR fixed 0.71 CI 0.33 to 1.52, I-squared 0%). Very limited data indicated that visual memory might decline after ECT compared with sham ECT (n=24, 1 RCT, WMD -14.0 CI -23 to -5); the results of verbal memory tests were equivocal. When ECT is directly compared with antipsychotic drug treatments (total n=443, 10 RCTs) results favour the medication group (n=175, 3 RCTs, RR fixed 'not improved at the end of ECT course' 2.18 CI 1.31 to 3.63). Limited evidence suggests that ECT combined with antipsychotic drugs results in greater improvement in mental state (n= 40, 1 RCT, WMD, Brief Psychiatric Rating Scale -3.9 CI - 2.28 to -5.52) than with antipsychotic drugs alone. One small study suggested more memory impairment after a course of ECT combined with antipsychotics than with antipsychotics alone (n=20, MD serial numbers and picture recall -4.90 CI -0.78 to -9.02), though this proved transient. When continuation ECT was added to antipsychotic drugs, the combination was superior to the use of antipsychotics alone (n=30, WMD Global Assessment of Functioning 19.06 CI 9.65 to 28.47), or CECT alone (n=30, WMD -20.30 CI -11.48 to -29.12). Unilateral and bilateral ECT were equally effective in terms of global improvement (n=78, 2 RCTs, RR fixed 'not improved at end of course of ECT' 0.79 CI 0.45 to 1.39). One trial showed a significant advantage for 20 treatments over 12 treatments for numbers globally improved at the end of the ECT course (n=43, RR fixed 2.53 CI 1.13 to 5.66). The evidence in this review suggests that ECT, combined with treatment with antipsychotic drugs, may be considered an option for people with schizophrenia, particularly when rapid global improvement and reduction of symptoms is desired. This is also the case for those with schizophrenia who show limited response to medication alone. Even though this initial beneficial effect may not last beyond the short term, there is no clear evidence to refute its use for people with schizophrenia. The research base for the use of ECT in people with schizophrenia continues to expand, but even after more than five decades of clinical use, there remain many unanswered questions regarding its role in the management of people with schizophrenia.