Multicenter Observational Study of Electroconvulsive Therapy in Japan.

IntroductionMajor depressive episodes (MDEs) occur in mood disorders such as major depressive disorder (MDD) and bipolar disorder (BD), affecting nearly one in four U.S. adults over their lifetime. The neurotrophic hypothesis suggests that disruptions in growth factor signaling contribute to MDEs. While brain-derived neurotrophic factor (BDNF) is well-studied, vascular endothelial growth factor (VEGF) may also play a crucial role, though evidence of its association with MDEs is inconsistent. Understanding VEGF is important for identifying predictors of treatment outcomes, such as those related to electroconvulsive therapy (ECT). This study explores the relationship between VEGF and MDEs, focusing on implications for ECT effects.ObjectivesTo consolidate evidence from studies evaluating the association between VEGF and ECT outcomes in patients experiencing an MDE.MethodsA systematic search for published clinical trials and cohort studies was conducted on August 13, 2024, using keywords including ECT, VEGF, MDE, and mood disorders, with no language or publication date restrictions. We selected studies enrolling patients in a current MDE related to MDD or BD, excluding those focused on manic episodes. A fixed-effects or random-effects model was applied. Subgroup analyses were performed to investigate the data further.ResultsSeven studies involving 621 participants (61.9% female; mean age: 50.2 years) were preselected. Six studies measured plasma VEGF levels; one assessed cerebrospinal fluid (CSF) levels. Plasma VEGF levels did not differ significantly between healthy controls and MDE patients, either before (SMD = 0.02 [−0.17; 0.21], p = 0.84, I² = 0%) or after ECT (SMD = 0.11 [−0.21; 0.44], p = 0.50, I² = 0%). Of the five studies reporting post-ECT VEGF levels, three found a significant increase from baseline. A significant correlation was observed between baseline plasma VEGF levels and depression response to ECT (r = 0.34, Z = 4.92, p < 0.0001, I² = 0%). Of the five studies examining increased VEGF levels after ECT and symptom reduction, only one found a significant association. A sensitivity analysis indicated substantial heterogeneity when including the CSF study.ConclusionsPlasma VEGF levels were not significantly different in MDE patients compared to healthy controls, either before or after ECT. Baseline plasma VEGF levels positively correlated with ECT treatment response, suggesting they may provide neurotrophic support and predict outcomes. Despite robust findings and minimal heterogeneity, this analysis was limited by the low number of studies and small sample sizes. Further research is needed to explore the association between MDEs and VEGF, especially in the CSF, and to clarify the role of baseline VEGF in ECT treatment response.Disclosure of InterestI. Borja De Oliveira: None Declared, G. A. M. Alves: None Declared, D. Soler Lopes: None Declared, A. de Vasconcelos: None Declared, A. Stephany: None Declared, F. Reis Soares: None Declared, M. Kraide Piedade de Abreu: None Declared, M. Carbajal Tamez: None Declared, J. Quevedo Shareolder of: Instituto de Neurociencias Dr. Joao Quevedo, Grant / Research support from: LivaNova; and receives copyrights from Artmed Editora, Artmed Panamericana, and Elsevier/Academic Press, Consultant of: EMS, Libbs, and Eurofarma, Speakers bureau of: Myriad Neuroscience and AbbVie., M. Teranishi: None Declared

The authors describe four cases of catatonia in which topiramate treatment was used. Commonly effective therapies, including benzodiazepines and divalproex, were proven refractory. In all four cases, subjects experienced complete remission of catatonic symptoms and tolerated treatment well. In one case, all psychotropic medications were discontinued because the patient became delirious. The delirium resolved after discovery and treatment of a urinary tract infection. Catatonic agitation relapsed when topiramate was withdrawn but remitted again when topiramate and lorazepam therapy was restored. In two cases, continued topiramate therapy was accompanied by sustained remission. These case reports present a novel approach to the treatment of catatonia.

Treatment of mood disorders is one of the most challenging territories in elderly. Effectiveness of different treatment strategies could be related to age, sex and physical conditions. The side effect profile in this population also affects pharmacological interventions. Our review includes the neurostimulative treatment strategies in elderly. However, possible treatment strategies such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS) and deep brain stimulation (DBS) were less studied in elderly. ECT was found to be an effective treatment procedure in mood disorders. Few double-blind sham controlled studies were conducted and demonstrated effectiveness of TMS. DBS has lack of double-blind studies. ECT seems to be the golden standard for the treatment resistant elderly patients, yet side effect profile of ECT in elderly will be discussed. Double -blind sham controlled studies with larger samples are necessary to confirm preliminary results with transcranial direct current stimulation (tDCS), magnetic seizure therapy (MST) and VNS, DBS.

It is generally assumed that the elderly patients are more vulnerable to cognitive side effects after electroconvulsive therapy (ECT) than younger depressed patients. The current study aims to evaluate the nature and extent of changes across multiple domains of neurocognitive functioning in a group of elderly depressed patients after ECT. In this prospective naturalistic study, we included 42 depressed patients aged ≥55 years. Global cognitive function, memory, and executive function were assessed before ECT treatment and within one week (short-term post-ECT) and six months after ECT (long-term post-ECT). Associations between cognitive functioning and electrode placement, total number of treatment sessions, age, and the severity of depression at the time of cognitive measurement were studied. Our data offered no evidence of decline for any of the neurocognitive tests after ECT, given its power to detect the difference. Post-ECT improvement of neurocognitive functioning was statistically significant for the Mini-Mental State Examination, Visual Association Test, 10 Words Verbal Learning Test, and Expanded Mental Control Test. Effect sizes were medium to large. After six months, compared with post-ECT performance, statistically significant improvement was found only for the Trail Making Test-A and the Letter Fluency Test with small to medium effect sizes. In our severely depressed elderly patients, neurocognitive performance improved or did not change after ECT. Patients with poor cognitive function were not able to participate in neuropsychological assessment before ECT started. Consequently these results may not apply to patients with more severe cognitive impairment prior to the start of ECT.

Knowledge, attitudes, and experience of child and adolescent psychiatrists in Turkey concerning pediatric electroconvulsive therapy.

Cerebral Small Vessel Disease (CSVD) is a chronic, progressive vascular disorder that confers increased vulnerability to psychiatric syndromes, including late-life mood disorders. In this study, we investigated the impact of CSVD on electroconvulsive therapy (ECT) outcomes in patients with late-onset bipolar disorder (BD). A sample of 54 non-demented elderly patients (≥60years) with late-onset BD and treatment-resistant major depression, mixed state, or catatonia who underwent bilateral ECT were included in this naturalistic observational study. A diagnosis of CSVD was established based on brain neuroimaging performed before ECT. All patients were evaluated before and after ECT using the Brief Psychiatric Rating Scale (BPRS), the Hamilton Rating Scale for Depression (HAM-D), and the Clinical Global Impression scale (CGI). Of the total sample, 19 patients were diagnosed with CSVD (35.2%). No significant differences were observed at baseline between patients with and without CSVD. Overall, a response was obtained in 66%-68.5% of patients, with remission in 56.2%. No significant differences in ECT outcomes were found between those with and without CSVD, and both groups exhibited substantial improvements in symptom severity following ECT. The outcome of ECT in late-onset BD was not influenced by the presence of CSVD. This finding aligns with previous research on unipolar depression. Accordingly, ECT should be considered for elderly patients with late-onset BD, regardless of the presence of CSVD.

Objective Erotomania is a rare delusional disorder marked by the persistent, unfounded belief that another person is in love with the affected individual. While antipsychotic medications may alleviate the intensity of delusions, the core belief often persists, leading to significant emotional distress and potential behavioral risks. The aim of this study was to illustrate the potential therapeutic role of electroconvulsive therapy (ECT) in the treatment of chronic, treatment-resistant erotomania. Materials and Methods We present a case report of a patient with a lifelong erotomanic delusion, centered on the same individual, which persisted unchanged despite multiple pharmacological treatments. The patient underwent a course of ECT, and clinical observations were documented throughout the treatment process. In addition to symptom monitoring, we explored the cognitive mechanisms potentially involved in the therapeutic response, with particular attention to belief updating and cognitive flexibility. Results ECT led to a marked reduction in the patient’s conviction regarding the erotomanic delusion, alongside improvements in emotional regulation and daily functioning. These changes appeared to be sustained over time. The treatment was well tolerated, with no significant adverse effects reported. Conclusions This case suggests that ECT may be a viable option for patients with severe, treatment resistant erotomania. Beyond symptomatic relief, ECT may facilitate the recalibration of maladaptive beliefs by enhancing cognitive flexibility, supporting the view that belief updating mechanisms play a key role in the resolution of persistent delusions. Further studies are needed to systematically evaluate ECT’s efficacy in delusional disorders.

IntroductionEsketamine (ESK) nasal spray and interventional therapies including electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) are indicated for patients with treatment resistant depression (TRD). Little is known about healthcare resource use and associated costs of Medicaid beneficiaries, a population with a high burden of mental health disorders, initiating ESK, ECT or TMS. This study aimed to bridge this gap in knowledge.MethodsMedicaid-insured adults with evidence of TRD (≥2 unique antidepressants of adequate dose and duration) were selected from Merative™ MarketScan® Multi-State Medicaid Database (01/2016-06/2022). Based on therapy initiated on or after 03/05/2019 (ESK approval date for TRD), patients were classified into three cohorts: ESK, ECT, and TMS. Before treatment initiation (index date), patients had ≥12 months of continuous insurance eligibility (baseline period). Mental health (MH)-related resource use and payer costs (USD 2022) were reported per-patient-per-month (PPPM) during the follow-up period, which spanned the index date until the earliest continuous insurance eligibility or data end.ResultsESK cohort included 151 patients (mean age: 40.6 years; female: 70.2%), ECT cohort included 198 patients (mean age: 43.0 years; female: 60.6%), and TMS cohort included 140 patients (mean age: 39.5 years; female: 65.0%).During the follow-up period, the mean number of MH-related inpatient (IP) days trended lower in ESK cohort (0.09) relative to the ECT (3.72) and TMS (0.31) cohorts. Similarly, the mean number of MH-related emergency department (ED) visits trended lower in ESK cohort (0.07) relative to ECT (0.12) and TMS (0.26) cohorts. The mean number of MH-related outpatient (OP) visits in ESK cohort (4.83) trended higher than in ECT cohort (4.37) but lower than in TMS cohort (6.41). Mean MH-related acute care costs during the follow-up period trended lower in ESK cohort (IP: $76; ED: $29) relative to ECT (IP: $1,547; ED: $45) and TMS cohorts (IP: $238; ED: $123). Outpatient costs in ESK cohort ($1,632) exceeded OP costs in ECT ($1,023) and TMS ($1,051) cohorts.ConclusionIn this descriptive analysis, a trend towards lower use and costs of acute MH-related care was observed after the initiation of ESK relative to the initiation of ECT and TMS. This finding should be interpreted with caution, given potential differences in patient profiles, clinical history and setting of administration.FundingJanssen Scientific Affairs, LLC. Analysis Group is a consulting company that has provided paid consulting services to Janssen Scientific Affairs, LLC, which funded the development and conduct of this study.

Objective: Electroconvulsive therapy (ECT) is effective and generally safe in depression. Its effectiveness and side effects are suggested to be related to the electrical stimulus administered relative to the seizure threshold. Since aging seems to raise the seizure threshold in ECT, we reviewed the literature for evidence correlating advanced age and seizure threshold, and for hypotheses explaining why seizure thresholds might raise with age. Methods: Pubmed, PsychINFO, three standard works on ECT, and cross-references were searched for studies investigating seizure thresholds and/or associated factors in elderly depressed patients. Results: A total of 406 possibly relevant articles were found, of which 27 studies could be included. One very recently published study was included afterwards because of its significance. Aging was moderately associated with a raised initial seizure threshold with correlation coefficients ranging from 0.30 to 0.64 (p < 0.05). Also, seizure thresholds in elderly patients were more likely to raise during the ECT course. Reported hypotheses for these clinical phenomena include a decrease of neuroexcitability, changes in morphologic and functional characteristics of the brain, somatic comorbidity, and concomitant medication use. Conclusion: To optimize ECT in elderly patients, hypotheses and suggestions for further research are proposed regarding the moderate correlation between advanced age and initial seizure threshold and the rise in seizure threshold during the ECT course. Keywords: Aging, electroconvulsive therapy, review, seizure threshold

Asymmetric alternation of the hemodynamic response at the prefrontal cortex in patients with schizophrenia during electroconvulsive therapy: A near-infrared spectroscopy study

The use of electroconvulsive therapy (ECT) in the state hospital setting currently represents a very small percentage of the total overall use of this modality in the treatment of the mentally ill. Using records kept by a state hospital, we retrospectively identified all patients who had received ECT between the years 1986 and 1995. A review of the records at the state hospital from where patients were referred and the university hospital where ECT was administered was undertaken. Demographic and clinical characteristics, reasons for referral, symptom profile, ECT parameters, clinical outcomes, and restraint/ seclusion data were assessed. Over 10 years, 21 patients were treated with ECT, representing 0.4% of all admissions to the state hospital. Of these subjects, 17 records could be retrieved. The majority were women (N = 12; 71%) and were diagnosed with a mood disorder. Ten subjects (59%) were over the age of 60 years, 4 of whom were 70 years or older. Most patients had a state hospital length of stay of 1 year or less. The mean number of ECT treatments was 12.2. There were no medical complications that led to premature termination of ECT. Eleven patients (65%) were discharged either directly from the university hospital or within 10 days of readmission to the state hospital. Six of 7 patients who had restraint and seclusion episodes prior to ECT were found to have no further episodes afterwards. The seventh experienced a dramatic decrease in number and total hours of episodes. For a substantial minority of patients in this state hospital setting, ECT appears to have been an effective and safe form of treatment, and its use should be considered early rather than late in the course of hospitalization.

IntroductionThe World Health Organization declared the coronavirus outbreak a pandemic on March 11th 2020. Since then, the containment measures were leading to increasing mental health problems in the general population and worsening of some pre‑existing psychiatric conditions. To our knowledge, there are few studies characterizing the impact of the COVID‑19 pandemic on psychiatric hospitalizations across the world.ObjectivesWe aimed to compare the number and characteristics of the hospitalizations in the mental health department of a Portuguese psychiatric hospital from March 2nd 2019 to October 31st 2019 with those that occurred in the same period in 2020.MethodsWe conducted a retrospective observational study including all patients admitted to hospital during these periods (n=805). Sociodemographic data, clinical characteristics and information about the context of hospitalization were collected. Statistical analysis was performed using t Student Test, Mann‑Whitney and Chi‑square.ResultsIn the pandemic period there was a marked reduction in the number of psychiatric hospitalizations. There was a statistically significant difference in the median length of stay and in the percentage of involuntary hospitalizations between the two periods. In 2019, the most frequent International Classification of Diseases (10th Revision) diagnostic categories were F30‑F39 (mood disorders) and in 2020 were F20‑F29 (schizophrenia, schizotypal and delusional disorders).ConclusionsThe reorganization of services and the decrease in admissions through the emergency department may explain these results.Disclosure of InterestNone Declared

Special Report: Women’s Reproductive Mental Health—A Clinical Framework

ECT in Elderly Patients With Schizophrenia

Changes in plasma amino acids after electroconvulsive therapy of depressed patients