2. Safety and cost-benefit analysis

Electroconvulsive therapy in pregnant patients. (2013 ) Bulbul F, Copoglu US, Alpak G et al.
http://www.ncbi.nlm.nih.gov/pubmed/23890597

This was a retrospective study of 33 pregnant patients who received ECT treatment between 2005 and 2012 at a university hospital in Turkey. There was a response rate of 84%. There were no preterm births. Follow up was obtained on 27 babies; 24 of these were healthy, 2 had physical conditions and one had been stillborn, all not thought to be related to the ECT. The authors also review other available literature and conclude that the second trimester carries a greater risk in terms of psychiatric morbidity.

 

Maintenance electroconvulsive therapy up to 12 years. (2013) Elias A, Chathanchirayil SJ, Bhat R et al.
http://dx.doi.org/10.1016/j.jad.2013.11.005

This was a retrospective study of 17 patients who had undergone long term ECT. Cognitive function was assessed by the Mini-Mental State Examination (MMSE) and compared with the review of Neuropsychiatry Unit Cognitive Assessment Tool (NUCOG). The authors conclude that there was no significant difference in MMSE score before and after maintenance treatment or progressive deterioration on NUCOG score but acknowledged the fact that the sample size was small and the tests were not sensitive to all types of cognitive impairment associated with ECT.

 

Does electroconvulsive therapy cause epilepsy?. (2013) Ray AK, J of ECT;29:201-205.

This question is often asked. The author set out to find the rate of spontaneous seizures occurring after treatment and reviewed ten years of follow up case records of 619 patients who had ECT over a five year period from 1990-1995. Notes from an age, sex, diagnosis matched control group were also reviewed. No report of spontaneous seizure was found in the study group though one patient was excluded due to suspected neurosyphilis. Two patients in the control group experienced a single convulsion.

 

Long-term naturalistic follow-up of patients with bipolar depression and mixed state treated with electroconvulsive therapy.(2013) Medda P, Mauri M, Fratta S et al. J of ECT;29:179-188.

Thirty six patients were followed up for an average of one year following bilateral ECT. 80.5% patients were still in remission after six weeks. 36% showed a depressive relapse during follow up, ranging from 2 – 60 weeks post treatment. 47% of patients were in remission for more than 70% of the time. The duration of depressive episode was related to early relapse..

 

Continuation electroconvulsive therapy with pharmacotherapy alone for prevention of relapse in depression. (2013). Nordenskjold A, vKnorring L, Ljung T et al., J of ECT 29:86-92.

This was a non blinded controlled trial which showed that a combination of antidepressant and continuation ECT was statistically more effective than medication alone in preventing relapse in 56 patients treated for a major depressive episode.

 

Prevention of relapse with maintenance electroconvulsive therapy in elderly patients with major depressive episode. (2013). Rapinesi C, Kotzalidis G, Serata D et al. J of ECT; 29:61-64.

Further evidence on the safety of maintenance ECT is presented in this study of seven elderly patients treated in this neuroscience department in Italy.

 

Benefits of returning to work after ECT. (2013). Berg J. J of ECT;29: 29-32.

Ten out of 16 patients who were treated with ECT in this Norwegian study were able to return to work after a mean of 14.7 months on sick leave. The authors call for the use of ECT earlier in the treatment algorithm than keep it as a treatment of last resort.

 

Is the use of electroconvulsive therapy falling because of fewer referrals of patients with severe depression? (2012). Scott A., Journal of ECT; 28:162-164.

Between the years of 2005 and 2006 the rate of use of ECT at this Edinburgh clinic fell from 1.33 to 0.82 per 10,000 total population. Review of diagnoses showed that the number of patients suffering from a severe depressive episode had remained consistent. The author concluded that the fall in ECT numbers related to a fall in those patients being referred for treatment of other conditions including moderate depressive episodes and other mood disorders.

 

One-year follow up after discontinuing maintenance electroconvulsive therapy. (2012). Huukha K., Viiki M., Tammentie T. et al., Journal of ECT; 28:225-228.

The authors set out to answer the question of relapse rate after successful continuation / maintenance ECT over a six month period or discontinuation because of patient refusal or medical reasons. Forty-five patients were followed up for one year following discontinuation. Forty four percent (n=20) relapsed, most within the first 3 months and all by 8 months. Those most likely to relapse had a diagnosis other than major depressive disorder. Patients taking antidepressants tended to have a lower relapse rate. The rate or relapse was similar to that following an acute episode of ECT. The authors support the use of long term c/m ECT for patients who relapse.

 

Twice versus thrice weekly ECT in a clinical population: an evaluation of patient outcomes. (2012). Psychiatry Research; vol 199, issue 3;208-211.

Further evidence from Australia to support the fact that twice weekly ECT is as effective as thrice weekly. Medical records were reviewed over a two year period; these referred to 119 patients and 150 treatment courses.

 

Maintenance electroconvulsive therapy (M-ECT) after acute response. Examining the evidence for who, what, when and how? (2012). Rabheru K. Journal of ECT 28; 39-47.

The author carried out a review of the published literature since 1997and concluded that there is now an increasing body of evidence to support the use of continuation ECT if other maintenance treatments have failed.

Measuring consistency of autobiographical memory recall in depression.(2012). Semkovska M, Noone M, Carton M et al. Psychiatry Research 197; 41-48.

The authors performed two related studies. The first focussed on the consistency of recall over a six month period in health volunteers. The second did the same in depressed patients who never had ECT. Both groups were consistent in loss of most components of semantic and episodic memory over time. However the depressed group were distinguishable from controls in relation to episodic-specific memories leading to the conclusion that research on cognitive side-effects at ECT needs to take into account normal loss of consistency over time and the effect of depressive illness.

ECT efficacy and treatment course: A systematic review and meta-analysis of twice vs thrice weekly schedules.(2012). Charlson F, Siskind D, Doi SAR et al., Journal of Affective Disorders 138; 1-8.

The paper provides further evidence to support the fact that giving thrice weekly ECT is no more effective that twice weekly. However twice weekly ECT, although requiring fewer treatments, was associated with longer course duration and this may have implications for access to inpatient beds.

The safety of electroconvulsive therapy in patients with prolonged QTc intervals on the electrocardiogram. (2011). Pullen S, Rasmussen K, Angstman E et al. Journal of ECT; 27: 192-200.

The charts of 1437 patients were reviewed and data produced supported a connection between baseline QTc interval and relative risk for developing a cardiac related side-effect.

Safety of electroconvulsive therapy in patients with a history of heart failure and decreased left ventricular systolic function. (2011). Rivera F, Lapid M, Sampson S et al. Journal of ECT 27: 207-213.

There was a successful outcome in the 35 patients with cardiac failure and decreased left ventricular funtion who underwent ECT over a 14 year period. Prophylactic treatment with beta blockers was used if patients were hypertensive or suffering from tachycardia pre-treatment.

Influence of age on effectiveness and tolerability of electroconvulsive therapy. (2010). Damm J, Eser D, Schule C et al. Journal of ECT;26:282-288.

The authors reviewed the case notes of 380 patients and classified elderly as those over 60yrs. This group, accounting for 30% of the total, were more likely to be suffering from a mood disorder rather than schizophrenia. There was no relationship between improvement, as evidenced by the GCI scale, and age although there were age related effects on the three neurophysiological measures recorded (post suppression index, convulsive energy index, convulsion concordance index). Higher severity of illness at admission and female sex correlated with improvement. There was a significant increase in the prescription of drugs for medical conditions in the elderly group and increased rates of transient disturbance of cognitive and cardiac function were also observed.

ECT efficacy and treatment course: a systematic review and meta-analysis of twice vs thrice weekly schedules. (2011). Charlston F, Siskind D, Doi S et al. Journal of Affective Disorders, doi:10.1016/j.jad.2011.03.039.

The authors reviewed literature to 2009 analysing outcome of a total of 214 patients. Twice weekly ECT was associated with similar efficacy to thrice weekly, requiring fewer treatments but over a longer time frame.

Comparison of electroconvulsive therapy (ECT) with or without anti-epileptic drugs in bipolar disorder (2010). Virupaksha H., Shashidhara B., Thirthalli J et al. Journal of Affective Disorders 127;66-70.

This was a study of the case records of 79 patients on anti-epileptic drugs (AED) for bipolar compared to 122 controls. Both groups responded well to ECT but the AED group required a significantly greater number of sessions and a longer period in hospital, presumably in part because of the associated higher incidence of failed treatments. The AED group had a significantly greater proportion of males, a longer duration of illness and a higher degree of co-morbidity.

ECT efficacy and treatment course: A systematic review and meta-analysis of twice versus thrice weekly schedules (2011). Chalrson F., Siskind D., Doi S et al. Journal of Affective Disorders. Doi:10.1016/j.jad.2011.03.0339.

This epidemiological study supports the routine use of twice weekly ECT which was associated with equal efficacy to thrice weekly treatment Although patients in this category needed fewer treatments they appeared to require a longer period of hospitalisation.

Electroconvulsive therapy and its place in the management of depression. (2011). Singhal A. Progress in Neurology and Psychiatry; 19-26.

A review article that includes a brief history, procedure at ECT and a description of current practice in the UK. The Royal College of Psychiatrists guidelines are summarised and compared to the NICE guidance that was issued in 2003. The author believes that the key to success is in the careful selection of patients and lists the most common clinical indications for treatment.

A critical examination of bifrontal electroconvulsive therapy: clinical efficacy, cognitive side-effects and directions for future research. (December 2008). Crowley K et al. Journal of ECT; 24:268-271.

The authors remind us of the need to develop tests to pick up cognitive side-effects involving frontal lobe function (for example executive function) before concluding that bifrontal ECT offers benefits over the more traditional bitemporal and unilateral electrode placements.

Effect of concomitant pharmacotherapy on electroconvulsive therapy outcomes. Short-term efficacy and adverse effects. (2010). Sackeim HA, Dillingham EM, Prudic J et al. Arch Gen Psychiatry;66(7):729-737.

This was a prospective, randomised, triple blind, placebo controlled trial over a 5 year period in three hospitals comparing the outcome of high dose unilateral with bilateral ECT, with or without nortriptyline or venlafaxine. Patients receiving concomitant antidepressants had a better outcome and unilateral ECT was as efficacious as bilateral and with less severe cognitive side-effects.

Cognition in elderly patients receiving unilateral and bilateral electroconvulsive therapy: A prospective, naturalistic comparison. (2009). O'Connor DW, Gardner B, Eppingstall B et al. Journal of Affective Disorders. doi:10.1016/j.jad.2009.11.022.

The authors reviewed recent studies of ECT in the elderly population and set out to recruit from six centres to study the effects of different treatment modalities. Sixty three patients were involved and the authors concluded that bilateral ECT at 1.5 times seizure threshold was no more effective that unilateral ECT at 3 times threshold and resulted in greater impairment of immediate verbal memory and autobiographical memory.

A critical examination of bifrontal electroconvulsive therapy: clinical efficacy,cognitive side-effects and directions for future research. (December 2008), Crowley K et al. Journal of ECT; 24:268-271.

The authors remind us of the need to develop tests to pick up cognitive side-effects involving frontal lobe function (for example executive function) before concluding that bifrontal ECT offers benefits over the more traditional bitemporal and unilateral electrode placements.

Strategies to minimise cognitive side-effects with ECT: aspects of ECT technique. March 2008. Joan Prudic, Journal of ECT. 24:46-51

A nice summary of the factors that contribute to cognitive side effects, namely: electrical waveform, electrode placement, stimulus intensity (dose), frequency and number of treatments.

Individualised 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. September 2008. Odeberg H et al, Journal of ECT; 24:183-190.

The timing of continuation ECT was triggered by signs of relapse in the 41 patients studied. Concomitant medication was recorded. By the end of the three year period the hospital bed days had reduced by 76%

Efficacy of maintenance electroconvulsive therapy in recurrent depression: a naturalistic study. September 2008. Gupta S et al. Journal of ECT; 24:191-194

The authors acknowledge the difficulty that UK practitioners now face in the light of the National Institute for Health and Clinical Governance (NICE) guidelines on maintenance ECT. They looked back at the outcome of 19 of their own patients who had been given maintenance ECT, pre NICE, and concluded that inpatient days fell significantly compared to pre treatment levels. The improvement was also maintained after stopping treatment.

Anticonvulsants during electroconvulsive therapy: review and recommendations. Sienaert P & Peuskens J. June 2007. Journal of ECT;23:120-123.

The authors undertook a MEDLINE search for 1985-2006 and concluded that there was no published evidence that suggested a combination of anticonvulsant drugs and ECT either caused increased side-effects or altered outcome. At the time of publication there had been no randomised prospective studies reported.

Monitoring electroconvulsive therapy by electroencephalogram: an update for practitioners. Scott A. July 2007. Adv in Psychiatric Treatment, vol 13,298-304.

An update on the latest published research on prolonged seizure activity at ECT together with practical tips on assessing the EEG in the clinic. It is not yet possible to examine an individual tracing and make accurate predictions about outcome but the quality of EEG tracings may add to decisions about treatment modality.

Serum sodium does not correlate with seizure length or seizure thereshold in electroconvulsive therapy. Rasmussen K, Mohan A, Stevens S. September 2007. Journal of ECT;23:175-176.

A study of 207 patients, some of whom had mild abnormalities relating to hypo and hypernatraemia. The numbers were not statistically significant but the authors conclude that whilst it is preferable to correct any biochemical abnormalities that minor changes in serum sodium level did not affect the seizure threshold or seizure length.

All-cause mortality among recipients of electroconvulsive therapy. Munk-Olsen et al. British Journal of Psychiatry (2007),190,435-439.

The cause of death of 783 patients who had received ECT over a 25 year period was analysed. Patients who had received ECT had a lower overall mortality rate from natural causes but a slightly higher suicide rate, especially in the first 7 days after treatment.

Health related quality of life following ECT in a large community sample. Vaughn McCall et al. Journal of Affective Disorders 90 (2006) 269-274.

This naturalistic study of 283 depressed patients assessed both quality of life and cognitive impairment post ECT and at 24 weeks later. Health related factors improved with recovery from depression despite the fact that cognitive impairment was associated with this improvement in the short term.  In contrast, at 24 week follow up improvement in cognitive status was associated with better quality of life. Failure to respond to ECT was not associated with a fall in quality of life relative to baseline.

Imipramine is effective in preventing relapse in electroconvulsive therapy-responsive depressed inpatients with prior pharmacotherapy treatment failure: a randomised placebo controlled trial. Van den Broek et al. J Clin Psychiatry 67: Feb 2006. http://www.ncbi.nlm.nih.gov/pubmed/16566622

This is a study of 27 patients over a 4 year period who were  given ECT for major depressive disorder. At six month follow up there was an 80% relapse rate on placebo compared to 18% on imipramine. This was despite the fact that mostpatients (22/27) had failed to respond to a tricyclic antidepressant and 24/27 to lithium augmentation prior to ECT.

Continuation and maintenance electroconvulsive therapy for the treatment of depressive illness: a response to the National Institute for Clinical Excellence report. Frederikse M, Petrides G, Kellner C. Journal of ECT 2006;22(1):13-17.

This review of recent literature suggests that continuation ECT is an important option especially for those patients who have responded well to an acute course of ECT. The authors give a description of the methodology used in the Consortium for Research in ECT Group (CORE) study on maintenance ECT, the first large-scale, randomised controlled trial involving ECT and due for publication in the near future.

Health related quality of life and the practice of electroconvulsive therapy. Rosenquist et al. Journal of ECT 2006;22(1):18-24.

This review outlines the measures used in health related quality of life (HRQL) studies and summarises HRQL studies looking at ECT, including the study by McCall et al referred to above. The authors conclude that there is an emerging literature which demonstrates the importance of ECT in restoring function and quality of life in depressed patients.

Is ECT cost-effective? A critique of the National Institute of Health and Clinical Excellence’s report on the economic analysis of ECT. McDonald W. Journal of ECT 2006;22(1):25-29.

The NICE technology appraisal of ECT concluded that it was cost neutral compared to antidepressant therapy. However this article questions the validity of this conclusion on the grounds that patient groups were not well matched for severity of illness.

The safety of electroconvulsive therapy and lithium in combination. September 2005. Dolenc T & Rasmussen K. Journal of ECT. 21(3):165-170.

This was a study of a series of 12 patients whose lithium treatment was continued during ECT without significant complications arising. The authors provide a useful summary of the literature and recommendations include the continued use of lithium if this has previously proved effective as a mood stabiliser or anti-manic, advising that lithium levels should be kept at the lower end of the therapeutic range.

No brain perfusion impairment at long-term follow-up in elderly patients treated with electroconvulsive therapy for major depression. Navarro V et al. June 2004. Journal of ECT 20:89-93.

Three groups of elderly patients were subjected to SPECT scanning: 1) 14 patients, one year after successful ECT, 2) 22 who were euthymic for one year following pharmacotherapy and 3) 25 age and sex matched controls. No significant differences in brain perfusion were detected.

Implications of herbal alternative medicine for electroconvulsive therapy. Patra K & Coffey E. September 2004. Journal of ECT 20:186-194.

A useful review of the effects that herbal remedies and alternative medicines might have on the effects and side-effects of ECT.

Efficiency of outpatient ECT. Dew R and McCall WV. Journal of ECT 20(1):24-25

This was an eight month prospective survey comparing the rates of completion of outpatient, maintenance and inpatient ECT. 77 patients were included and completion rates were 65% for inpatients, 62% for acute outpatients and 91% for maintenance outpatients. The authors conclude that resources for maintenance outpatients can be predicted and that this is a highly efficient and cost-effective option.

Electroconvulsive Therapy Clinics in the United Kingdom should routinely monitor Electroencephalographic Seizures. Benbow S, Benbow J, Tomenson B. Journal of ECT December 2003. 19:217-220.

95 courses of ECT were studied; prolonged seizures (over 120 secs EEG) were detected in 19% of patients and there was marked disparity between EEG and motor activity. On 19 occasions the EEG recorded cerebral seizure activity in the absence of a motor fit, on one occasion this was prolonged.

Effects of Maintenance Electroconvulsive Therapy on Cognitive Functions. Vothknecht S et al. Journal of ECT September 2003, 19(3):151-157.

There was no difference detected in the cognitive function of the two study groups, a group of 11 patients on maintenance ECT and 13 control patients treated with maintenance pharmacotherapy. Tests used included the Wechsler memory scale, Benton visual retention, Stroop colour-word test, 10-word verbal learning test and tests of background intelligence. All patients improved clinically as measured by reduction in HRSD and BDI scores.

United Kingdom National Survey of the Views of Geriatric Psychiatrists on the Administration of Electroconvulsive Therapy to Patients with Fractures.Shah A & Benbow S. Journal of ECT December 2002;18(4):203-206.

This postal survey reported that 12% of the geriatric psychiatrists who responded had given ECT to patients with fractures. Advice was sought from anaesthetists and orthopaedic surgeons before treatment.

ECT Use Delayed in the Presence of Comorbid Mental Retardation: A Review of Clinical and Ethical Issues.Little J, McFarlane J, Ducharme H. Journal of ECT December 2002;18(4):218-222.

The authors, on review of the literature, are concerned that the use of ECT may be un-necessarily late in the treatment algorithm for this population.

Effective Use of Electroconvulsive Therapy in Late-Life Depression.Flint AJ and Gagnon N. Canadian Journal of Psychiatry, October 2002;47:734-741.

The authors reviewed the literature from the last ten years on efficacy safety and tolerability of ECT in the elderly. They found a correlation between advancing age and efficacy and concluded that cognitive side-effects from bilateral ECT were related to pre-existing dementia rather than age per se.

A Dental Risk Management Protocol for Electroconvulsive Therapy. Morris J et al. Journal of ECT 18(2):84-89.

This article describes the inclusion of a quality assurance checklist for oral assessment prior to ECT.

ECT Treatment of Malignant Catatonia/NMS in an Adolescent: A Useful Lesson in Delayed Diagnosis and Treatment.Ghaziuddin at al. Journal of ECT 18(2):95-98.

This is a case report of a seventeen year old girl with NMS who underwent six weeks of investigation and evaluation before being successfully treated with ECT

Continuation and Maintenance ECT: A Review of Recent Research. Andrade C & Kurinji S. Journal of ECT. 18(3):149-158.

The authors reviewed the last ten years of the published literature on the treatment of depressive illness and schizophrenia and concluded that ECT emerges as a safe and effective treatment for patients who have responded well to a course of ECT and are liable to relapse.

Safety, Efficacy and Effects on Glycemic Control of Electroconvulsive Therapy in Insulin-Requiring Type 2 Diabetic Patients. Netzel P et al. March 2002. Journal of ECT 18(1):16-21.

The authors concluded there were no significant changes in glycemic control for the 19 insulin dependent diabetics (143 treatments) studied in this series, refuting previous reports that ECT can result in dangerous hyperglycaemia or decreased insulin requirements.

ECT in mental retardation: a review.Van Waaarde JA, Stolker JJ, van der Mast RC. Journal of ECT December 2001. 17(4):236-243.

A review of the literature from the last 34 years using Medline, Embase and Cochrane produced case studies of 44 patients with learning difficulties who were given ECT. The authors conclude that the indications and response to treatment were similar to the general population (84% effectiveness for psychotic depression) but that factors such as complicated assessment, legal and ethical issues probably cause an unnecessarily limited use of ECT in this population.

Laboratory screening prior to ECT.Lafferty J et al. The Journal of ECT, September 2001, 17(3): 158-165.

A review of the electrocardiogram and measurement of sodium and potassium levels appeared to be useful screening tests which detected correctable unexpected conditions relevant to risk in the 562 patients evaluated in this study.

The hippocampus in patients treated with electroconvulsive therapy.Ende et al. October 2000, Archives of General Psychiatry, 57,10,937.

The results of this study provide reassurance that there is no atrophy or cell death in the hippocampus (an area concerned with memory) after ECT.

Administration of citalopram before ECT: seizure duration and hormone responses.Papakostas Y et al. December 2000, Journal of ECT, 16(4):356-360.

A study of 20 patients randomly allocated to citalopram 20mg or placebo 2 hours before their 3rd and 4th ECT reported no significant difference in seizure duration and no adverse events.

Seizure activity and safety in combined treatment with venlafaxine and ECT: a pilot study.Bernardo et al, March 2000, Journal of ECT, vol 16, no1, 38-42.

A study of nine patients on Venlafaxine at 150mg/day who received ECT without adverse effects.

Balancing speed of response to ECT in major depression and adverse cognitive effects: role of treatment schedule.Shapira et al. June 2000, Journal of ECT 16(2):97-109.

The results of two double blind studies concurring with the previous conclusion that twice weekly ECT is the most optimum schedule for routine clinical practice unless speed of response is an overriding concern.

Burke W.I., Rubin E.H., Zorumski C.F., Wetzel R.D. (1987),The safety of ECT in geriatric psychiatry. Journal of American Geriatrics Society. 35(6):516-21.

Devanand D.P., Dwork A.J., Hutchison E.R. et. al. (1994), Does ECT alter brain structure? , AM J Psychiatry 151: 957-70.

Fink M (1979),Risk-benefit analysis. Convulsive therapy: theory and practice, Chapter 5. Raven press.

Price T. R. P., McAllister Y.W. (1989), Safety and efficacy of ECT in depressed patients with dementia: a review of clinical experience. :Convulsive therapy, 5 , (1):61-74.

Zielinski R.J., Roose S.P., Devanand D.P., Woodring S., Sackeim H.A. (1993), Cardiovascular problems in depressed patients with cardiac disease. American Journal of Psychiatry. 150(6):904-909.