Effectiveness of maintenance electroconvulsive therapy—Evidence from modifications due to the COVID‐19 pandemic

OBJECTIVE: Continuation and maintenance ECT (c‐/m‐ECT) are effective in the prevention of relapse and recurrence of both affective and psychotic disorders. However, data are scarce concerning the trajectories of severe mental disorders after the end of c‐/m‐ECT. This prospective study investigates the clinical outcome of patients with versus without modifications of their c‐/m‐ECT schedules. METHODS: In the context of the COVID‐19 pandemic, ECT capacities were restricted at many clinics in early 2020. All patients receiving c‐/m‐ECT in March and April 2020 at our department (n = 53, unipolar depression, bipolar disorder, schizophrenia) were followed up for six months to investigate the impact of treatment modifications imposed by the pandemic. Based on individual decisions, c‐/m‐ECT was either (a) continued without modification, (b) continued with reduced frequency, or (c) discontinued. RESULTS: Both reduced frequency and discontinuation of c‐/m‐ECT were associated with significant clinical deterioration as measured by CGI‐I (Clinical Global Impression Scale ‐ Global Improvement) during the six‐month follow‐up when compared to the subgroup of patients without any treatment modification (p = 0.005, p = 0.011). Furthermore, patients with discontinued or reduced c‐/m‐ECT showed significantly higher rates of rehospitalizations (p = 0.028) and new acute courses of ECT (p = 0.018). CONCLUSION: Despite the limitations of a heterogeneous and relatively small sample, our study strongly corroborates the effectiveness of c‐/m‐ECT in a real‐world population. Especially, patients with shorter time since index ECT seem to be at high risk for severe clinical deterioration in the case of treatment discontinuation or reduction

Health service aspects of electroconvulsive therapy: analysis of external referrals to a university medical center

Zusammenfassung Hintergrund Die Anwendungshäufigkeit der Elektrokonvulsionstherapie (EKT) in Deutschland variiert stark in Abhängigkeit von der regionalen Verfügbarkeit. Teilweise wird dieses Versorgungsdefizit durch Zuweisungen an EKT-durchführende Kliniken kompensiert, was jedoch durch dort verfügbare Ressourcen limitiert ist. Ziel der Arbeit Untersuchung der externen Zuweisungen zur EKT am Beispiel der Universitätsmedizin Göttingen. Analysiert werden sollen die Zuweiserstruktur, die Patientencharakteristika, die leitliniengerechte Pharmakotherapie vor Indikationsstellung zur EKT sowie das Therapieoutcome im Falle einer Behandlung mit EKT. Material und Methoden Externe Anmeldungen zur EKT wurden über ein Jahr systematisch erfasst und retrospektiv ausgewertet. Neben der deskriptiven Darstellung der Daten erfolgte der Abgleich pharmakologischer Vorbehandlungen mit den aktuellen Leitlinienempfehlungen. Das Therapieoutcome nach durchgeführter EKT wurde mittels des klinischen Gesamteindrucks (CGI-I) bestimmt. Ergebnisse Für N  = 52 Patienten erfolgte die Anfrage zur Übernahme, davon kamen 82,7 % aus dem stationären Setting und aus einer Entfernung von bis zu 300 km. Unipolare Depressionen (57,7 %) und Störungen aus dem Schizophreniespektrum (36,5 %) waren die häufigsten Diagnosen. Vor Zuweisung erfolgte in der Mehrheit der Fälle mindestens eine leitliniengerechte Vorbehandlung. Bei 18 Patienten wurde eine EKT in unserem Haus durchgeführt, von diesen zeigten 72,7 % ein gutes bis sehr gutes Ansprechen. Diskussion Anzahl und Radius der Zuweisungen zeigen einen hohen ungedeckten Bedarf in der Versorgung mit EKT und damit einen eingeschränkten Zugang zu einer evidenzbasierten und leitlinienempfohlenen Therapie. Im Sinne einer heimatnahen Behandlung ist anzustreben, EKT als Therapieangebot an mehr Kliniken zu etablieren. Auch bei externen Zuweisungen und damit verbundenen, zum Teil erheblichen Verzögerungen ist die Ansprechrate diagnoseübergreifend gut.Abstract Background The application of ECT in Germany varies widely depending on regional availability. This shortfall in ECT supply is partly compensated via referrals to hospitals with ECT services, yet restricted by limited resources in these clinics. Objective External referrals for ECT were investigated at the University Medical Center Göttingen. We analyzed the referring institutions, patient characteristics, pharmacotherapy according to current guidelines before indications for ECT, and clinical outcome in cases of treatment with ECT. Material and methods All external referrals were systematically recorded and retrospectively evaluated for the time span of 1 year. Besides descriptive presentation of the data, pharmacological pretreatment was compared with the current guideline recommendations. We used overall clinical impression (CGI-I) to determine the treatment response post-ECT. Results External referrals were made for N  = 52 patients, 82.7% of whom were from the inpatient setting and from a distance of up to 300 km. The most common diagnoses were unipolar depression (57.7%), followed by schizophrenia spectrum (36.5%). Prior to referral, at least one guideline-based pretreatment was given in the majority of cases. ECT was performed in 18 patients in our hospital, of whom 72.7% showed a good to very good response. Conclusion Both numbers and radius of external referrals indicate a high unmet need for ECT and thus limited access to this evidence-based and guideline-recommended therapy. As treatment close to home should be the goal, more hospitals are needed to establish (or expand) ECT services; however, even with considerable delays which are often associated with external referrals, the response rate is good across all diagnoses

Effects of Anesthesia Changes During Maintenance ECT: A Longitudinal Comparison of Seizure Quality Under Anesthesia Using Propofol/Esketamine Versus Methohexital

Abstract Introduction The effectiveness of ECT relies on the induction of a generalized cerebral seizure. Among others, seizure quality (SQ) is potentially influenced by the anesthetic drug used. Commonly used anesthetics comprise barbiturates, etomidate, propofol, and esketamine, with different characteristics and impacts on seizure parameters. So far, no studies have compared the influence of methohexital vs. a combination of propofol/esketamine on established SQ parameters. Methods This retrospective longitudinal study compared eight established SQ parameters (PSI, ASEI, MSC, midictal amplitude, motor and electroencephalography (EEG) seizure duration, concordance, PHR) before and after the change from propofol/esketamine to methohexital in 34 patients under maintenance ECT. Each patient contributed four measurements, two before and two after the anesthesia change. Anesthesia dose, stimulus dose, electrode placement, and concomitant medication remained unchanged throughout the analyzed treatments. Results Under methohexital (M=88.97 mg), ASEI (p=0.039 to 0.013) and midictal amplitude (p=0.022 to<0.001) were significantly lower, whereas seizure duration (motor and EEG) was significantly longer when compared to propofol/esketamine (M=64.26 mg/51.18 mg; p=0.012 to<0.001). PSI, MSC, seizure concordance, and PHR were not affected by the anesthetic used. Discussion Although to what extent these parameters correlate with the therapeutic effectiveness remains ambiguous, a decision for or against a particular anesthetic could be considered if a specific SQ parameter needs optimization. However, no general superiority for one specific substance or combination was found in this study. In the next step, anesthetic effects on treatment response and tolerability should be focused on

Influence of depressed patients' expectations prior to electroconvulsive therapy on its effectiveness and tolerability (Exp-ECT): a prospective study

Electroconvulsive therapy (ECT) is the most effective therapy for severe depressive disorders. Though there are known clinical predictors of response (e.g., higher age, presence of psychotic symptoms), there is a lack of knowledge concerning the impact of patients' expectations on treatment outcome and tolerability in terms of possible placebo/nocebo effects. In 31 patients with unipolar or bipolar depressive disorder, we used a questionnaire to investigate the patients' expectations of ECT effectiveness and tolerability prior to and in the course of the treatment. Additionally, the questionnaire was used after the ECT course for a final assessment. Depressive symptoms and putative side-effects were measured at each time point. General linear models were used to analyze the course of depressive symptoms and patients' expectation of ECT effectiveness and tolerability. ECT significantly reduced depressive symptoms with large effect sizes. Patients' rating of ECT effectiveness decreased in parallel: While responders' rating of ECT effectiveness remained stable on a high level, non-responders' rating decreased significantly. Group difference was significant after, but not prior to and during the treatment. Regarding tolerability, there was a (temporary) significant increase in the severity of self-rated symptoms such as headache and memory impairment. In contrast, patients' expectation and assessment of ECT tolerability remained unchanged, and their expectations prior to ECT had no impact on the occurrence of side-effects. These findings contradict the presence of relevant placebo/nocebo effects in the context of ECT when investigating a population of mostly chronic or treatment resistant patients with moderate to severe depressive disorder