Survey of the practice of electroconvulsive therapy in teaching hospitals in India

OBJECTIVES: We sought to obtain an overview of electroconvulsive therapy (ECT) practice in teaching hospitals in India. METHOD: From September 1, 2001, to August 31, 2002, a 29-item questionnaire enquiring about ECT practice during the past year was sent to 188 teaching institutions and psychiatric hospitals. RESULTS: Seventy-four institutions (39.4%) completed the questionnaire. ECT was available in 66 institutions. A total of 19,632 patients received 114,111 instances of ECT from 316 psychiatrists, of which 13,891 patients (70.8%) received 89,475 treatments (78.4%) from 128 psychiatrists in the psychiatric hospitals. The male-to-female ratio was 1.56 to 1. Brief-pulse device was used in 39 institutions. EEG monitoring was used routinely in only 8 institutions. Bilateral ECT was used in almost all institutions. Patients with schizophrenia received ECT most frequently (36.5%), followed by patients with major depression (33.5%), mania (17.9%), catatonia (6.2%), and dysthymia (2.8%). Patients who received ECT were in age group of 45-64 years (43.9%), followed by 25-44 years (34.5%), 65 years and older (14.7%), 18-24 years (5.6%), and younger than 18 years (1.4%). A total of 10,234 patients (52%) received unmodified ECT 52,450 treatments (46%) at 33 institutions. There was one case of ECT-related death during a survey. Continuation ECT was performed in 29 institutions and maintenance ECT in 17. CONCLUSIONS: More than 70% of ECT administrations in India were performed in the psychiatric hospitals. Approximately half of ECT use was unmodified ECT. The majority of patients who received ECT were diagnosed with schizophrenia and major depression. ECT training programs for psychiatry residents were acceptable.     

Practice of electroconvulsive therapy at the research and training hospital in Turkey

Objective  We sought to obtain an overview of electroconvulsive therapy (ECT) practice in Bakirkoy Research and Training Hospital for Psychiatric and Neurological Diseases, which is the biggest hospital for psychiatry in Turkey. Method  From 1st January 2006 to 30th June 2007, a form enquiring about evaluation of ECT was filled retrospectively. Results  The total number of patients, admitted for psychiatry during the survey period was 265,283. A total of 1,531 patients (12.4% among inpatients and 0.58% in all psychiatric admissions) received 13,618 sessions (including multiple hospitalizations) of ECT from 12,341 psychiatric inpatients during the survey period. Ninety-eight patients had multiple hospitalizations. The male-to-female ratio was 1.26–1. Patients with bipolar affective disorder, current episode manic with or without psychotic symptoms received ECT most frequently (30.3%), followed by patients with schizophrenia (29.5%), severe depressive episode with or without psychotic symptoms (include bipolar affective disorder current episode severe depression) (15.2%), other non-organic psychotic disorders (14.4%), schizoaffective disorders (6.3%), mental and behavioral disorders due to psychoactive substance abuse with psychotic disorders (3.5%) and catatonic schizophrenia (0.7%). Patients who received ECT were in age group of 25–44 years (64.7%), followed by 45–64 years (17.7%), 18–24 years (15.4%), 65 years and older (1.4%), and younger than 18 years (0.8%). All patients received modified ECT. There were no ECT-related deaths during the survey. Conclusion  The rate of ECT among all psychiatric inpatients during the survey period was 12.4%. The majority of patients who received ECT were diagnosed with bipolar affective disorder-current episode manic and schizophrenia. ECT training programs for psychiatry residents and specialists should be planned, and conducted systematically.     

ECT practice in Japan

OBJECTIVES: We sought to determine the characteristics of electroconvulsive therapy (ECT) practice in Japan. Only by knowing practice patterns can standards of care be successfully developed and implemented. METHODS: From September 1, 2001, to August 31, 2003, a questionnaire was sent to 248 institutions. RESULTS: A total of 100 institutions (40.3%) completed the questionnaire. ECT was available in 83 institutions. A total of 1,210 patients received 11,146 ECTs from 895 psychiatrists. Brief-pulse device was used in 21 institutions. EEG monitoring was used routinely in 15 institutions. Bilateral ECT was always used. Patients who received ECT were diagnosed schizophrenia (48.9%), major depression (37.4%), catatonia (6.8%), mania (4.4%), and dysthymia (0.8%). The majority of patients who received ECT were in the age group 45-64 years (40.4%) and 65 years and older (39.3%). A total of 670 patients received a total of 6364 unmodified ECT at 60 institutions. There were no ECT-related deaths during the survey. CONCLUSION: ECT use in Japan is low. More than half of ECTs instituted were unmodified. The majority of patients who received ECT were diagnosed with schizophrenia and major depression.     

A questionnaire survey of ECT practice in Australia

OBJECTIVE: To determine the characteristics of electroconvulsive therapy (ECT) practice in Australia. METHOD: From October 1, 2002 to February 29, 2004, a 29-item questionnaire was sent to 136 hospitals in Australia. RESULTS AND CONCLUSIONS: One hundred thirteen hospitals (83%) completed the questionnaire. Electroconvulsive therapy was available in 90 hospitals. A total of 7469 patients received 58,499 ECTs from 356 psychiatrists, which gives an average course length of 8.5 treatments. Electroconvulsive therapy use as assessed by the crude treated-person rate was 37.85 persons per 100,000 population per annum. Of the number of patients, 63.4% were women. Brief-pulse devices were used in all hospitals. Electroencephalogram monitoring was used routinely in 80 hospitals. Of the total number of ECT treatments, 82.3% were given to patients with major depression, 9.6% to patients with schizophrenia, 4.9% to patients with mania, and 1.7% to patients with catatonia. Patients who received ECT were in an age group older than 65 years (38.4%), followed by 45 to 64 years (28.3%), 25 to 44 years (26.3%), 18 to 24 years (6.9%), and less than 18 years (0.2%). Unmodified ECT was not used in any hospital. One thousand one hundred ninety-six patients received continuation ECT in 83 hospitals, and 1044 received maintenance ECT in 77 hospitals. There was no case of ECT-related death during a survey period. Only 31 hospitals rated their teaching program for medical students as acceptable to excellent, and for psychiatry residents, it was 58.     

Efficacy of continuation ECT and antidepressant drugs compared to long-term antidepressants alone in depressed patients

OBJECTIVE: The purpose of this study was to evaluate the efficacy of continuation ECT in depression. METHOD: The authors used retrospective chart review to identify 29 patients who received continuation ECT plus long-term antidepressant treatment after a positive response to acute treatment with ECT for a depressive episode (continuation ECT group). A retrospective case-controlled approach was used to ascertain a matching group of 29 patients who received long-term antidepressant treatment alone after responding positively to acute ECT (antidepressant-alone group). All 58 patients (46 with unipolar depression, 12 with bipolar disorder) had been chronically depressed before receiving acute ECT. Data from medical records were analyzed by using survival analysis and proportional hazards regression to determine outcome and risk factors. RESULTS: The mean duration of the follow-up period for all patients was 3.9 years (5.4 years for the continuation ECT patients and 2.4 years for the antidepressant-alone patients). Outcome was significantly better in the continuation ECT group. The cumulative probability of surviving without relapse or recurrence at 2 years was 93% for continuation ECT patients and 52% for antidepressant-alone patients. At 5 years, survival declined to 73% for continuation ECT patients, but fell to 18% for antidepressant-alone patients. Mean survival times were 6.9 years for the continuation ECT patients and 2.7 years for the antidepressant-alone patients. CONCLUSIONS: The findings provide strong support for the efficacy of continuation ECT plus long-term antidepressant treatment in preventing relapse and recurrence in chronically depressed patients who have responded to acute treatment with ECT.     

Individualized continuation electroconvulsive therapy and medication as a bridge to relapse prevention after an index course of electroconvulsive therapy in severe mood disorders: a naturalistic 3-year cohort study

Electroconvulsive therapy (ECT) is recognized as an effective acute treatment for mood disorders but is associated with high risk of relapse. To minimize this risk, we introduced as a routine individually tapered continuation ECT with concomitant medication (C-ECT + Med) after an index series in January 2000. In August 2002, a chart review of all patients (n = 41) who had received C-ECT + Med for more than 4 months was carried out. Sixteen patients also participated in an extensive interview. Mean duration of administered C-ECT at follow-up was 1 year, but for most patients (63%), C-ECT had been terminated. For 49% of patients, adjustments between ECT sessions had been made due to early signs of relapse. Two weeks was the most common interval between sessions for patients with ongoing C-ECT. The frequency of lithium-treated patients had increased from 12% before index to 41% during C-ECT. However, the rated response to the drug varied. Need for hospital care 3 years before and after the initiation of C-ECT + Med was compared in a second evaluation of the cohort. The number of patients hospitalized, number of admissions, and total days in hospital were all significantly reduced. Hospital days were reduced by 76% (P < 0.001). Three patients with previously cumulative years in hospital are described as case vignettes after 6 years with no or minimal need for further hospitalization. This study supports previous findings that individually tapered C-ECT + Med can maintain initial response to ECT and serve as a bridge to long-term relapse prevention.     

Clinical outcome and adverse effects of electroconvulsive therapy in elderly psychiatric patients

We evaluated the short-term outcome and side effects of electroconvulsive treatment (ECT) in a population of elderly psychiatric patients. The material included patients consecutively hospitalized at a psychogeriatric department within a period of 5 years. From a total number of 239 patients, we included 52 treated with ECT (22%). Altogether, 41 patients (79%) improved clinically. Of them, 21 (40%) of the patients went home after the treatment. Twenty patients (38%) developed adverse reactions from the ECT treatment. Impaired memory (14%), confusion (6%), and hypertension (6%) represented the most commonly reported negative reactions secondary to the treatment. The findings from the study support previous assumptions that ECT is effective in the treatment of serious psychiatric disorders in elderly patients. Because of the relative high frequency of side effects, the patients should be selected     

Response to treatment of depression in the old and very old

Treatment responses were monitored in 101 depressed patients, ranging in age from 64 to 92 years, hospitalized on a geropsychiatry unit. Forty-six percent of the patients received ECT. Medications were used in the majority of patients. Responses were assessed with both depression inventories (Beck Depression Inventory and Geriatric Depression Scale) and physician-rated global improvement scores. Advanced age was not associated with poor outcome. ECT was the most important variable associated with a good response, regardless of age.     

Clinical characteristics associated with relapse 2 years after electroconvulsive therapy for major depression

Objective

High relapse rates are observed after electroconvulsive therapy (ECT) for major depression. Identifying patients who are at increased risk for relapse to intensify their treatment regimen post-ECT might reduce relapse rates. We aimed to determine clinical characteristics that are associated with relapse within 2 years after successful ECT.

Methods

Patients who remitted to ECT in a randomised controlled trial comparing adjuvant nortriptyline and placebo during a course of bilateral ECT were followed-up prospectively for 1 year with open-label nortriptyline (Dutch Trial Register NTR5579). Second-year follow-up data were collected retrospectively. Thirty-four patients were included in this follow-up cohort. To examine the association between clinical characteristics and the risk of relapse, unadjusted hazard ratios (HRs) were calculated.

Results

At 2 years post-ECT, the overall relapse rate was 50%, and the HRs for relapse in patients with psychotic features, a higher severity of depression, and medication resistance prior to ECT were 0.33 (CI 0.12–0.89; p = 0.029), 0.88 (CI 0.80–0.98; p = 0.014), and 4.48 (CI 1.28–15.73, p = 0.019), respectively. No effect was found for age, sex or episode duration on the relapse rate.

Conclusions

Depressed patients with psychotic features, with higher symptom severity and without medication resistance prior to ECT have a significantly decreased risk of relapse after successful ECT. A sustained remission rate of 50% over 2 years in patients with severe major depression who were treated with nortriptyline monotherapy after successful ECT is encouraging.     

Acute efficacy of ECT in the treatment of major depression in the old-old

OBJECTIVE: There are few data addressing the outcome of ECT for persons over 75 years of age. In a prospective, multisite study, the authors compared characteristics and treatment outcomes of adult (59 and younger), young-old (60 to 74 years), and old-old (75 and older) patients treated with ECT for major depression. METHOD: At four hospitals, 268 patients with primary unipolar major depression and scores of at least 20 on the 24-item Hamilton Depression Rating Scale were treated with suprathreshold right unilateral or bilateral ECT in a standardized manner. Demographic variables, clinical characteristics, and short-term outcomes of the three groups were compared. RESULTS: The demographic and clinical characteristics of the old-old patients were similar to those of the young-old patients, whereas both groups differed from the adult patients on these variables. Both older groups had significantly greater burdens from physical illness and global cognitive impairment at baseline than the adult subjects. Both older groups had shorter index depressive episodes and were less likely to have had inadequate responses to adequate medication trials before ECT. The older groups had higher seizure thresholds, but the three groups received similar courses of treatment. The adult patients experienced a significantly lower rate of ECT response (54%) than the young-old patients (73%), while the old-old patients had an intermediate rate of response (67%). CONCLUSIONS: Despite a higher level of physical illness and cognitive impairment, even the oldest patients with severe major depression tolerate ECT in a manner similar to that for younger patients and demonstrate similar or better acute response.     

Reduced length and cost of hospital stay for major depression in patients treated with ECT

To investigate the effect of treatment modality on length of hospital stay, the authors retrospectively studied 86 admissions of 74 patients with major depression. All 19 patients who received ECT recovered, in contrast to only 27 (49%) of 55 patients given tricyclic antidepressants or other medication. The 28 patients who had not responded to antidepressants recovered after treatment with ECT. Treatment modality had a highly significant effect on length of hospital stay: patients given ECT stayed a mean of 13 fewer days, saving more than $6,400 per patient at current rates. These findings of significant economic and therapeutic benefits in the use of ECT raise issues about treatment selection for depressed inpatients.     

A randomized comparison of high-charge right unilateral electroconvulsive therapy and bilateral electroconvulsive therapy in older depressed patients who failed to respond to 5 to 8 moderate-charge right unilateral treatments

BACKGROUND: Electroconvulsive therapy (ECT) is the treatment of choice in some older patients with severe depression. When compared with younger depressed patients, older patients have been shown to be as likely to respond to ECT but more likely to develop cognitive impairment. This study addresses whether adults aged 50 years and over who have already failed to respond to at least 5 moderate-charge right unilateral (RUL) ECT treatments (150% above seizure threshold) are more likely to benefit from a switch to high-charge RUL ECT (450% above threshold) or to bilateral (BL) ECT. METHOD: Twenty-four patients who were treated with 5 to 8 moderate-charge RUL ECT treatments and who failed to improve sufficiently were randomly assigned to receive either BL ECT (N = 11) or high-charge RUL ECT (N = 13). Depressive (24-item Hamilton Rating Scale for Depression) and cognitive scores (Mini-Mental State Examination [MMSE]) were compared under double-blind conditions at 3 phases of treatment. RESULTS: Patients in the BL ECT group exhibited significantly greater cognitive impairment (mean MMSE score decrease of 1.13) than those receiving high-charge RUL ECT (mean MMSE increase of 1.71). There were no statistically significant differences in clinical response to BL or high-charge RUL ECT (63.6% and 61.5%, respectively) or in depressive symptom remission (18.1% and 46.2%). CONCLUSION: These results suggest that older patients who fail to respond to moderate-charge RUL ECT may benefit from a switch to high-charge RUL ECT rather than BL ECT. Larger future studies will be needed to compare clinical response in patients switched from moderate-dose RUL ECT to higher-dose RUL or to BL ECT.     

The use of electroconvulsive therapy in the elderly: a study from the psychiatric unit of a north Indian teaching hospital

OBJECTIVES: There are very little data on elderly patients receiving electroconvulsive therapy (ECT) in India. This study was a preliminary attempt at characterizing the clinical and demographic profile of elderly subjects (>or=60 years) who received ECT in the psychiatric department of a teaching hospital in north India. METHODS: A retrospective case-note review was carried out to identify patients 60 years or older who had received ECT over an 8-year period at the Postgraduate Institute of Medical Education and Research, Chandigarh, India. Several details about their demographic and clinical profile, indications for ECT, response patterns, and adverse effects were extracted. RESULTS: Over the 8 years, 373 patients received ECT, of which 56 (15%) were 60 years or older. Complete records were available for only 50 of these patients. The majority (96%) had depression. The index depressive episode for which ECT was used was severe in 91.6% of the subjects, and 68% had not responded to adequate psychotropic treatment before ECT. Comorbid medical illnesses were present in 66% of cases and were associated with significantly higher risk of cognitive side effects. However, side effects were usually mild; there were no serious untoward events caused by ECT. About 80% to 90% showed some response to treatment. Those who had received inadequate antidepressant treatment before ECT were significantly more likely to respond to ECT. CONCLUSIONS: Elderly with depression constitute a substantial proportion of those receiving ECT in India. Use of ECT in this population seemed to be mainly restricted to those who were very severely ill and poorly responsive to medications. Electroconvulsive therapy seemed to be a safe and effective treatment in such situations. However, particular care may be required in the subgroup with comorbid physical problems that may be more vulnerable to cognitive adverse effects.     

Electroconvulsive therapy in the very old

At least one study has questioned the safety of electroconvulsive therapy (ECT) in the very old. In this study, the authors reviewed a 5-year experience with ECT at two university psychiatric services for patients 75 years of age or older. Both outcomes and complications were reviewed. Nineteen of 22 patients (86.3%) were ECT responders. Five patients (22.7%) suffered complications which varied from minor to substantial. ECT was found to be an effective and reasonably safe treatment for depression in the very old.     

Electroconvulsive therapy for treating schizophrenia: a chart review of patients from two catchment areas

To examine disease and treatment characteristics of patients with schizophrenia treated with electroconvulsive therapy (ECT). We examined charts from 79 patients diagnosed with schizophrenia (n = 55), persistent delusional disorders (n = 7), and schizoaffective disorders (n = 17) between 2003 and 2008. We recorded age, sex, indication for ECT, number of ECT sessions, ECT series, outcome, maintenance ECT, use of antipsychotics, duration of illness, and duration of the current exacerbation. All patients were taking antipsychotics at the time of enrolment in the study. Acute ECT included 2–26 sessions; maintenance ECT (M-ECT) was given to 18 patients for up to 12 years. Initial indications for ECT included psychosis (n = 28), pronounced affective symptoms (n = 28), delirious states (n = 20), and M-ECT (n = 3). Most patients experienced excellent/good outcomes (n = 66), but others experienced moderate (n = 8) or poor (n = 5) outcomes. No factors were identified that predicted treatment responses in individual patients. ECT proved to be effective in a population of patients that were severely ill with treatment-refractory schizophrenia. This does not imply that the patients were cured from schizophrenia. Rather, it reflects the degree of relief from psychosis and disruptive behaviour, as described in the patient charts. The treatment was often offered to patients after considerable disease durations.     

Perceptions of outcome from electroconvulsive therapy by depressed patients and psychiatrists

OBJECTIVE: To determine (i) patients' expectations before and attitudes after a course of electroconvulsive therapy (ECT); (ii) the concordance between the perceptions of patients and their psychiatrists; and (iii) whether patients and psychiatrists are accurate in predicting a positive outcome with ECT. METHOD: Eighty-one inpatients (mean 67.2 years, median 70 years) with major depression were assessed before and after receiving a course of ECT. On both occasions, patients were administered the Hamilton Rating Scale for Depression (HRSD) and the Global Assessment of Functioning Scale (GAF). Patients and two research psychiatrists rated their expectancy of treatment outcome before ECT and their impression of outcome after ECT was completed. RESULTS: Both HRSD and GAF scores improved with treatment. Before treatment, 39.7% of patients believed ECT would improve their condition. Following treatment, 68.8% of patients thought their condition had improved as a result of ECT. There was only slight agreement between patients' and psychiatrists' expectations before and ratings of efficacy after treatment. The psychiatrists', but not the patients', pretreatment expectations of ECT efficacy were significantly associated with improvement in depression as measured by the effect size change in HRSD score from pre- to post-ECT. CONCLUSIONS: Patients were poor judges of ECT outcome and, in this sample, less positive than previous reports had suggested. Psychiatrists' expectations however, were generally accurate indicating good clinical selection.     

Predictors of remission after electroconvulsive therapy in unipolar major depression

CONTEXT: Electroconvulsive therapy (ECT) is the most effective biological treatment for major depression. However, there is little agreement about clinically useful predictors of acute ECT outcomes. OBJECTIVE: To assess whether age, sex, burden of comorbid physical illness, age at onset, history of recurrence, episode duration, chronic depression or comorbid dysthymia, melancholic features, episode severity, and medication resistance are predictors of remission after an acute course of ECT. DESIGN: We performed an analysis using data gathered prospectively in 328 patients with unipolar major depression (according to Research Diagnostic Criteria) treated with ECT. The study was conducted from 1993 through 1999. Patients had a pretreatment score of 21 or higher on the 24-item Hamilton Rating Scale for Depression (HAM-D). Treatment history was assessed using the Antidepressant Treatment History Form. Remission was defined as a 24-item HAM-D score of 10 or less and a 60% or more relative reduction of the HAM-D score. RESULTS: On univariate logistic regression, statistically significant predictors of nonremission were chronic depression/dysthymia, medication resistance, longer episode duration, and younger age. On backward elimination logistic regression, only medication resistance (OR = 1.67, 95% CI = 1.05 to 2.67) and chronic depression/ dysthymia (OR = 1.84, 95% CI = 1.06 to 3.21) were statistically significant predictors of nonremission. CONCLUSIONS: In patients with major depression, lower rates of remission after acute ECT are associated with medication resistance and chronicity, but not with age or burden of physical illness.     

Bifrontal electroconvulsive therapy in the elderly: a 2-year retrospective

OBJECTIVES: We sought to examine the clinical effect of bifrontal (BF) electroconvulsive therapy (ECT) in depressed patients aged 65 years and older. METHODS: A retrospective chart review of all patients who received BF ECT for a depressive disorder between January 2000 and December 2002 was made. RESULTS: Fourteen patients, with a mean age of 73.9 years, received BF ECT. Nine had unipolar and 5 had bipolar depression. Twelve patients (86%) responded unequivocally after a mean of 8.5 treatments. Five (35%) experienced cognitive side effects. Ninety-two percent of patients were discharged on lithium (0.6 mmol/L) with 86% also receiving antidepressants or antipsychotics. Only 1 patient relapsed, the remainder remaining well at follow-up after a mean of 18.7 months. CONCLUSION: BF ECT was found to be clinically effective and associated with cognitive side effects in elderly patients who were experiencing a depressive episode of either unipolar or bipolar origin.     

Electroconvulsive therapy in psychiatrists and their families.

In answer to allegations by electroconvulsive therapy (ECT) detractors that psychiatrists never prescribe the treatment for themselves or their families, I sought clinicians with personal or family experience as ECT patients. A letter inviting first-hand accounts of treatment was published in a commonly read psychiatric publication (Psychiatric News) and mailed to selected American Psychiatric Association District Branches. Forty-two psychiatrists responded. Ten practicing psychiatrists had received at least one ECT series, five during their training years, and one had taken one treatment for personal educational reasons ("to see what my patients were experiencing"). More than 80 series and maintenance courses of ECT were described among 11 psychiatrists, nine parents, five siblings, and 18 other relatives of psychiatrists. Almost all patients had moderate to excellent improvement; no serious adverse effects were reported. Inability to get ECT for depressive relapses years after earlier, positive responses may have contributed to two suicides. Three psychiatrists published their personal or family experience with ECT in medical journals. A number of brief case reports are presented. It appears that psychiatrists and their families are consumers of ECT in much the same way as are patients from the general population.