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Electroconvulsive Therapy: Abstracts

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American Journal of Psychiatry 134:9, September 1977. pp: 1010-1013.

Shock Treatment, Brain Damage, and Memory Loss: A Neurological Perspective

John M. Friedberg, M.D.

The author reviews reports of neuropathology resulting from electroconvulsive therapy in experimental animals and humans. Although findings of petechial hemorrhage. gliosis. and neuronal loss were well established in the decade following the introduction of ECT. they have been generally ignored since then. ECT produces characteristic EEG changes and severe retrograde amnesia. as well as other more subtle effects on memory and learning. The author concludes that ECT results in brain disease and questions whether doctors should offer brain damage to their patients.

Clinical Neuropsychology (1982) 4(2): 62-66

Can ECT Permanently Harm the Brain?

Donald I. Templer and David M. Veleber

Literature relevant to the question of whether ECT permanently injures the brain was reviewed. Similar histological findings of epileptics and patients who had received ECT were discussed. Experimental research with animals seems to have demonstrated both reversible and nonreversible pathology. Psychological test findings, even when attempting to control for possible pre-ECT differences, seem to suggest some permanent cognitive deficit. Reports of spontaneous seizures long after ECT would appear to point to permanent brain changes. Human brain autopsies sometimes indicate and sometimes do not indicate lasting effects. It was concluded that vast individual differences are salient, that massive damage in the typical ECT patient is unlikely, and that irreversible changes probably do occur in some patients.

International Journal of Risk & Safety in Medicine 11 (1998) 5-40 IOS Press

Electroshock: scientific, ethical, and political issues.

Peter R. Breggin.

Abstract. Electroconvulsive treatment (ECT) is increasingly used in North America and there are attempts to promote its further use
world-wide. However, most controlled studies of efficacy in depression indicate that the treatment is no better than placebo with no
positive effect on the rate of suicide.

ECT is closed-head electrical injury, typically producing a delirium with global mental dysfunction (an acute organic brain syndrome).
Significant irreversible effects from ECT are demonstrated by many studies, including: (1) Inventories of autobiographic and current events
memories before and after ECT; (2) Retrospective subjective observations on memory; (3) Autopsy studies of animals and some of humans.
ECT causes severe and irreversible brain neuropathology, including cell death. It can wipe out vast amounts of retrograde memory while
producing permanent cognitive dysfunction.

Contemporary ECT is more dangerous since the current doses are larger than those employed in earlier clinical and research studies. Elderly
women, an especially vulnerable group, are becoming the most common target of ECT. Because of the lopsided risk/benefit ratio, because it
is fundamentally traumatic in nature, because so many of the patients are vulnerable and unable to protect themselves, and because
advocates of ECT fail to provide informed consent to patients - ECT should be banned.

Does Electroconvulsive Therapy Prevent Suicide?

Victor Milstein, Ph.D., Joyce G. Small, M.D., Iver F. Small, M.D., and Grace E. Green, B.A.

Larue D. Carter Memorial Hospital and Indiana University School of Medicine. Indianapolis, Indiana, USA.

Summary: To examine the issue of whether or not electroconvulsive therapy (ECT) protects against suicidal death, we followed a complete population of 1,494 adult hospitalized psychiatric patients for 5-7 years. During that time there were 76 deaths of which 16 or 21% were by suicide. Cause of death was not significantly related to age. gender or research diagnosis. Patients who committed suicide were more apt to have received ECT than those who died from other causes, but this difference was not significant. A control group of living patients matched for age, sex, and diagnosis had very similar exposures to ECT. which further indicates that ECT does not influence long-term survival. These findings combined with a close examination of the literature do not support the commonly held belief that ECT exerts long-range protective effects against suicide.

Am J Psychiatry 1994 Nov;151(11):1657-61

Use of ECT in the United States in 1975, 1980, and 1986.

Thompson JW, Weiner RD, Myers CP.

Department of Psychiatry, University of Maryland School of Medicine, Baltimore.

OBJECTIVE: The objective was to analyze nationally representative data from the National Institute of Mental Health (NIMH) to update trends in the use of ECT in the United States.

METHOD: The data are estimates from the NIMH Sample Survey Program for 1975, 1980, and 1986, which include representative samples of inpatients in psychiatric facilities in the United States. The authors' analyses use trend data from public general hospitals, private general hospitals, private psychiatric hospitals, and state and county mental hospitals. They report on126,739 patients who received ECT in 1975, 1980, and 1986, focusing on data from 1980 and 1986.

RESULTS: In 1986, 36,558 patients received ECT. This represents a decrease from the 1975 figure (58,667 patients) but no change from 1980 (31,514 patients). ECT was used primarily in private general hospitals (64%) and private psychiatric hospitals and much less often in public general hospitals and state and county mental hospitals. In 1986 over 90% of ECT recipients were white, and 84% had an affective disorder diagnosis. Although 71% of the patients who received ECT were women, hospital type and age were more important than gender in predicting ECT use. Individuals 65 years of age and older received ECT out of proportion to their numbers in inpatient care.

CONCLUSIONS: The declining use of ECT in the United States ended in the 1980s. Few African Americans receive ECT, and its use is becoming more targeted toward patients with affective disorders. The amount of services research done on this modality is very small. Basic questions have yet to be answered, including who refers patients for ECT and why, and how ECT fits into the overall course of treatment.

N Engl J Med 1993 Mar 25;328(12):839-46

Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy.

Sackeim HA, Prudic J, Devanand DP, Kiersky JE, Fitzsimons L, Moody BJ, McElhiney MC, Coleman EA, Settembrino JM

Department of Biological Psychiatry, New York State Psychiatric Institute, NY 10032.

BACKGROUND. The efficacy of electroconvulsive therapy in major depression is established, but the importance of the electrical dosage and electrode placement in relation to efficacy and side effects is uncertain.

METHODS. In a double-blind study, we randomly assigned 96 depressed patients to receive right unilateral or bilateral electroconvulsive therapy at either a low electrical dose (just above the seizure threshold) or a high dose (2.5 times the threshold). Symptoms of depression and cognitive functioning were assessed before, during, immediately after, and two months after therapy. Patients who responded to treatment were followed for one year to assess the rate of relapse.

RESULTS. The response rate for low-dose unilateral electroconvulsive therapy was 17 percent, as compared with 43 percent for high-dose unilateral therapy (P = 0.054), 65 percent for low-dose bilateral therapy (P = 0.001), and 63 percent for high-dose bilateral therapy (P = 0.001). Regardless of electrode placement, high dosage resulted in more rapid improvement (P < 0.05). Compared with the low-dose unilateral group, the high-dose unilateral group took 83 percent longer (P < 0.001) to recover orientation after seizure induction, whereas the combined bilateral groups took 252 percent longer (P < 0.001). During the week after treatment, there was three times more retrograde amnesia about personal information with bilateral therapy (P < 0.001). There were no differences between treatment groups in cognitive effects two months after treatment. Forty-one of the 70 patients who responded to therapy (59 percent) relapsed, and there were no differences between treatment groups.

CONCLUSIONS. Increasing the electrical dosage increases the efficacy of right unilateral electroconvulsive therapy, although not to the level of bilateral therapy. High electrical dosage is associated with a more rapid response, and unilateral treatment is associated with less severe cognitive side effects after treatment.

Publication Types:
Clinical trial
Randomized controlled trial

Comment in:
N Engl J Med. 1993 Mar 25;328(12):882-3

PMID: 8441428

J ECT 2000 Jun;16(2):133-43

Electroconvulsive therapy and memory loss: a personal journey.

Donahue AB

The cause for the significant gap between research and anecdotal evidence regarding the extent of some memory loss after electroconvulsive therapy (ECT) has never been adequately explained. A patient's development of awareness and self-education about her severe side effects from ECT raises questions regarding many current assumptions about memory loss. ECT-specific studies, which conclude that side effects are short term and narrow in scope, have serious limitations, including the fact that they do not take into account broader scientific knowledge about memory function. Because of the potential for devastating and permanent memory loss with ECT, informed consent needs significant enhancement until advancing research on both improved techniques and on better predictive knowledge regarding memory loss progresses to making a greater impact on clinical applications. Follow-up care and education in coping skills need to be a regular part of ECT practice when patients do experience severe effects.

PMID: 10868323

Arch Gen Psychiatry 2000 Jun;57(6):581-90

The effects of electroconvulsive therapy on memory of autobiographical and
public events.

Lisanby SH, Maddox JH, Prudic J, Devanand DP, Sackeim HA

Department of Biological Psychiatry, New York State Psychiatric Institute, New
York 10032, USA. SHL24@columbia.edu

Note: Shortly after ECT, patients recalled fewer events and event details than controls, with the deficits most marked for impersonal compared with personal events. At the 2-month follow-up, patients had reduced retrograde amnesia, but continued to show deficits in recalling the occurrence of impersonal events and the details of recent impersonal events. The amnestic effects of ECT are greatest and most persistent for knowledge about the world (impersonal memory,) compared with knowledge about the self (personal memory), for recent compared with distinctly remote events, and for less salient events.

BACKGROUND: Retrograde amnesia is the most persistent cognitive adverse effect of electroconvulsive therapy (ECT); however, it is not known whether ECT has differential effects on autobiographical vs impersonal memories. This study examined the short- and long-term effects of differing forms of ECT on memory of personal and impersonal (public) events.

METHODS: Fifty-five patients with major depression were randomly assigned to right unilateral (RUL) or bilateral (BL) ECT, each at either low or high electrical dosage. The Personal and Impersonal Memory Test was administered by blinded raters at baseline, during the week after ECT, and at the 2-month follow-up. Normal controls were tested at matched intervals.

RESULTS: Shortly after ECT, patients recalled fewer events and event details than controls, with the deficits most marked for impersonal compared with personal events. Bilateral ECT caused more marked amnesia for events and details than RUL ECT, and especially for impersonal memories. These effects were independent of electrical dosage and clinical outcome. At the 2-month follow-up, patients had reduced retrograde amnesia, but continued to show deficits in recalling the occurrence of impersonal events and the details of recent impersonal events.

CONCLUSIONS: The amnestic effects of ECT are greatest and most persistent for knowledge about the world (impersonal memory,) compared with knowledge about the self (personal memory), for recent compared with distinctly remote events, and for less salient events. Bilateral ECT produces more profound amnestic effects than RUL ECT, particularly for memory of impersonal events.

Publication Types:
Clinical trial
Randomized controlled trial

PMID: 10839336

J Am Geriatr Soc 1990 Jul;38(7):753-8

Electroconvulsive therapy in octogenarians.

Cattan RA, Barry PP, Mead G, Reefe WE, Gay A, Silverman M

Section of Geriatrics, University of Miami School of Medicine, FL 33101.

Note: Patients over 80 years had significantly more cardiovascular complications and falls (95% confidence interval) and tended to have a worse ASA (American Society of Anesthesiologists) scale rating and a somewhat less successful outcome.

Medical records of 81 older patients (65 years of age and over) who underwent electroconvulsive therapy (ECT) at a university-affiliated private geriatric hospital were reviewed to evaluate the safety and efficacy of this treatment for depression in the "young-old" (65 to 80 years) compared with the "old-old" age group (over 80 years), a group that has not yet been adequately studied. Information was obtained regarding demographics, medical and psychiatric diagnosis, medications, indications for ECT, number and laterality of treatments, outcome, and complications. Thirty-nine patients 80+ years of age (mean age, 85 +/- 3.2) were compared with 42 patients 65 to 80 years of age (mean age, 74 +/- 5.2). Statistical analysis was performed using confidence intervals of the difference in proportions of patients in each group. There were no significant differences in the demographics, number and laterality of ECT treatments, indications for ECT treatment, medical diagnosis, medications, or prior history of falls, but psychiatric diagnoses differed slightly. Patients over 80 years had significantly more cardiovascular complications and falls (95% confidence interval) and tended to have a worse ASA (American Society of Anesthesiologists) scale rating and a somewhat less successful outcome.

This study confirms the role of ECT as a relatively safe and effective treatment, which may be lifesaving in selected depressed older patients. Prospective studies are needed to understand better the long-term outcome and to prevent the morbidity and mortality associated with ECT in this frail, high-risk older group.

PMID: 2370395

Convuls Ther 1997 Sep;13(3):125-7

The mortality rate with ECT.

Abrams R.

Chicago Medical School, North Chicago, Illinois 60064, U.S.A.

Note: Since there are no reporting requirements in most states, it's easy for ECT advocates to downplay the number of deaths resulting from the procedure. Here's an example from Richard Abrams, one of the country's most outspoken ECT advocates.

ECT is a low-risk procedure, even in the older cardiac patient who is fast becoming the modal candidate for this therapy. To put the mortal risk with ECT in proper perspective, it is only necessary to note that ECT is about 10 times safer than childbirth, that approximately 6 times as many deaths annually in the U.S. are caused by lightning as by ECT, that two complications of psychotropic drug therapy in younger women-fatal myocardial infarction and fatal subarachnoid hemorrhage-virtually never occur with ECT, and that the death rate reported for ECT is an order of magnitude smaller than the spontaneous death rate in the general population.

Br J Psychiatry 1996 Oct;169(4):423-9

Seven year prognosis in depression. Mortality and readmission risk in the Nottingham ECT cohort.

O'Leary DA, Lee AS.

Note: Over the course of the seven-year study, the risk of death doubled for patients receiving shock therapy. More than two-thirds of the shock patients had relapses and had to be readmitted during that time.

BACKGROUND: The longer term prognosis of depressed patients treated with ECT is relatively unknown. We describe seven-year mortality and readmission risks for the Nottingham ECT series.

 METHOD: Cases were defined and subtyped using the Present State Examination (PSE). Follow-up was naturalistic. Death and readmission were ascertained using the Nottingham case register.

 RESULTS: The risk of death was doubled (SMR = 1.99, 95% CI = 1.34-2.84, P < 0.001). The seven-year cumulative probability of remaining without readmission was 0.27 (95%  CI 0.19-0.35), being 0.79 (0.71-0.87) at 16 weeks (relapse) and 0.34 (0.24-0.44) thereafter (recurrence readmissions). Multiple regression analysis showed that delusions predicted relapse, while endogenous subtype, absence of psychomotor retardation, and previous history predicted recurrence readmissions.

CONCLUSION: Index ECT treatment predicted high longer-term mortality and readmission risks. PSE/CATEGO-based subtyping identified patients most vulnerable to relapse and recurrence.

PMID: 8894191

J ECT 2000 Mar;16(1):19-31

Relapse of depression after ECT: a review.

Bourgon LN, Kellner CH.

Department of Psychiatry, Faculty of Health Sciences, University of Ottawa, Ontario, Canada.

Relapse of severe depression after successful treatment with electroconvulsive therapy (ECT) continues to be a major problem. We review the literature on relapse after ECT and factors that predict relapse. Early studies showed that the relapse rate was approximately 50% without follow-up treatment and that the majority of these relapses occurred in the first 6 months. More recent studies have found even higher rates in delusional depression and possibly in "double depression." Studies of biological markers as predictors of relapse were examined. Six of nine studies of the dexamethasone suppression test and one study of cortisol hypersecretion show that post-ECT nonsuppressors are at higher risk; although insensitive for diagnostic purposes, this test may be useful, when persistently abnormal, as a predictor of relapse. Studies of the thyrotropin-releasing hormone stimulation test and shortened rapid eye movement sleep latency are inconclusive. Medication resistance pre-ECT has been shown to predict relapse in two studies and highlights the need for more aggressive and effective treatment in this group.

 Further research into the prediction and prevention of depressive relapse after ECT is needed, and the field anxiously awaits current trials comparing ECT with combination lithium and nortriptyline.

Publication Types:
Review
Review, tutorial

PMID: 10735328 [PubMed - indexed for MEDLINE]

J Clin Psychiatry 1999;60 Suppl 2:104-10; discussion 111-6

Electroconvulsive therapy and suicide risk.

Prudic J, Sackeim HA

Department of Biological Psychiatry, New York State Psychiatric Institute, College of Physicians and Surgeons, Columbia University, 10032, USA.

Note: Little, if any, evidence supports a long-term positive effect of ECT on suicide rates, especially if diagnostically heterogeneous groups are considered.

For major psychiatric disorders in which suicidality is often a symptom, electroconvulsive therapy (ECT) is an established, highly effective treatment. In fact, suicidal risk may be an indication for the use of ECT to treat those disorders. The authors present new data and review clinical experience that indicate that ECT often exerts a profound short-term beneficial effect on suicidality. Little, if any, evidence supports a long-term positive effect of ECT on suicide rates, especially if diagnostically heterogeneous groups are considered. However, patients may have been assigned ECT precisely because they were suicidal and, hence, these reports may represent underestimates. As a whole, the published reports are weakened by methodological shortcomings, such as lack of controls, weak design, and possible cohort effects. In fact, most studies were designed to examine the impact of ECT on mortality rates in general, and all but one study found reductions in overall mortality, the source of which remains undetermined.

J Affect Disord 1999 Dec;56(2-3):183-7

Retrospective controlled study of inpatient ECT: does it prevent suicide?

Sharma V

Mood Disorders Unit, London Psychiatric Hospital, Ontario, Canada.
vsharma@julian.uwo.ca

BACKGROUND: This study examined the use of ECT among inpatients who committed suicide at a provincial psychiatric hospital.

METHODS: A total of 45 psychiatric in-patients who committed suicide at a provincial psychiatric hospital were compared with a gender, age and admission diagnosis matched group of 45 hospitalized patients to examine the use of electroconvulsive therapy during the last 3 months of hospitalization.

RESULTS: No difference in the utilization of ECT was found in the two groups.

LIMITATIONS: Retrospective design and small sample size.

CONCLUSIONS: We failed to demonstrate that ECT had prevented suicide in hospitalized patients. Future prospective studies with large sample size are needed to further examine this question.

PMID: 10701475

Anaesthesia 1997 Sep;52(9):884-6

Cardiac rupture during electroconvulsive therapy.

Ali PB, Tidmarsh MD

Department of Anaesthesia, Leicester Royal Infirmary, UK.

A 57-year-old man with recurrent depression, resistant to drug therapy, was scheduled for a course of eight electroconvulsive therapy treatments. The patient had undergone seven treatments without incident over the previous 3 weeks. Immediately following the final treatment, the patient suffered cardiovascular collapse, culminating in cardiac arrest with electromechanical dissociation. Despite resuscitative measures, the patient died. Post-mortem examination found the cause of death to be cardiac tamponade, secondary to cardiac rupture.

PMID: 9349071

JAMA 1985 Oct 18;254(15):2103-8

Consensus conference. Electroconvulsive therapy.

Electroconvulsive therapy (ECT) is a treatment for severe mental illness in which a brief application of electric stimulus is used to produce a generalized seizure. In the United States in the 1940s and 1950s, the treatment was often administered to the most severely disturbed patients residing in large mental institutions. As often occurs with new therapies, ECT was used for a variety of disorders, frequently in high doses and for long periods. Many of these efforts proved ineffective, and some even harmful. Moreover, its use as a means of managing unruly patients, for whom other treatments were not then available, contributed to the perception of ECT as an abusive instrument of behavioral control for patients in mental institutions for the chronically ill. With the introduction of effective psychopharmacologic medications and the development of judicial and regulatory restrictions, the use of ECT has waned. The treatment is now used primarily in general hospital psychiatric units and in psychiatric hospitals. A National Institute of Mental Health hospital survey estimated that 33,384 patients admitted to hospital psychiatric services during 1980 were treated with ECT, representing approximately 2.4% of all psychiatric admissions.

Although ECT has been in use for more than 45 years, there is continuing controversy concerning the mental disorders for which ECT is indicated, its efficacy in their treatment, the optimal methods of administration, possible complications, and the extent of its usage in various settings. These issues have contributed to concerns about the potential for misuse and abuse of ECT and to desires to ensure the protection of patients' rights. At the same time, there is concern that the curtailment of ECT use in response to public opinion and regulation may deprive certain patients of a potentially effective treatment. In recent decades, researchers intensified efforts to establish the effectiveness of ECT and its indications, understand its mechanism of action, clarify the extent of adverse effects, and determine optimum treatment technique. Despite recent research effort yielding substantial information, permitting professional and public evaluation of the safety and efficacy of ECT, the investigation of ECT has not generally been in the mainstream of mental health research. To help resolve questions surrounding these issues, the National Institutes of Health in conjunction with the National Institute of Mental Health convened a Consensus Development Conference on Electroconvulsive Therapy from June 10 to 12, 1985.(ABSTRACT TRUNCATED AT 400 WORDS)

Am J Psychiatry 1995 Jul;152(7):995-1001

Predictors of retrograde amnesia following ECT.

Sobin C, Sackeim HA, Prudic J, Devanand DP, Moody BJ, McElhiney MC

Department of Biological Psychiatry, New York State Psychiatric Institute, NY 10032, USA.

OBJECTIVE: Substantial progress has been made in identifying how the treatment parameters used in ECT impact on cognitive side effects. However, there is limited information regarding individual differences in vulnerability to these side effects. The authors examined patients' pretreatment global cognitive status and postictal orientation recovery time as potential predictors of the magnitude of retrograde amnesia for autobiographical memories after ECT.

METHOD: Seventy-one inpatients with major depressive disorder were randomly assigned to four ECT conditions that varied in electrode placement (right unilateral versus bilateral) and stimulus dosage (low versus high intensity). Orientation recovery time was assessed at virtually every session during the course of ECT. Global cognitive status was assessed with the modified Mini-Mental State examination before treatment, during the week after termination of treatment, and 2 months after treatment ended. Retrograde amnesia was assessed at these same time points with the Autobiographical Memory Interview.

RESULTS: Pre-ECT global cognitive status and the duration of postictal disorientation were strong predictors of the magnitude of retrograde amnesia in the week after the course of ECT and at 2-month follow-up. In general, these relationships were maintained regardless of technical parameters in the administration of the ECT.

CONCLUSIONS: Patients who manifest global cognitive impairment before treatment and patients who experience prolonged disorientation in the acute postictal period may be the most vulnerable to persistent retrograde amnesia for autobiographical information.

J Am Geriatr Soc 1984 Mar;32(3):183-6

The clinical use of electroconvulsive therapy in old age.

Karlinsky H, Shulman KI.

A retrospective review was conducted on the charts of 33 elderly inpatients (age range, 62-85 years) who received electroconvulsive therapy (ECT) in a geriatric psychiatry unit of a general hospital. Electroconvulsive therapy was found to be safe but not uniformly effective; only 42.4 per cent of patients obtained an immediate good outcome. The implications of these findings for further evaluations of the indications and efficacy of ECT in old age are discussed.

Ned Tijdschr Geneeskd 1996 Feb 3;140(5):260-4

[Temporary results only in electroconvulsive therapy in therapy-resistant depression; retrospective study].

[Article in Dutch]

Lemstra A, Leentjens AF, van den Broek WW.

Academisch Ziekenhuis Rotterdam-Dijkzigt, afd. Psychiatrie.

OBJECTIVE. To evaluate the use and efficacy of electroconvulsive therapy (ECT) in refractory major depression according to DSM-III-R criteria, and to look for factors predicting response in the acute phase and the occurrence of relapse or recurrence after recovery. DESIGN. Retrospective.

 SETTING. University Hospital Rotterdam, The Netherlands.

METHODS. Of all patients who received ECT between January 1988 and July 1993 data were collected by study of clinical records and of information by treating physicians after discharge. Every patient was visited once, or received an outpatient department appointment, to obtain informed consent, take a follow-up history and evaluate social functioning by scoring Global Assessment of Functioning and Sickness Impact Profile rating scales.

RESULTS. 35 patients received ECT. In clinical practice, the guidelines of the Netherlands Psychiatric Association were not violated; most patients had received adequate pharmacological pretreatment before the decision to start ECT was made. Two patients died in hospital (not from ECT). In the acute phase 25 of the 33 patients still alive upon discharge showed good recovery. Seven of these suffered relapse within six months. The number of patients with a return of depressive symptoms rose to 12 by the end of the first year of follow-up. Sociodemographic variables and treatment characteristics did not appear to influence the result of treatment in the acute phase, nor the occurrence of relapse or recurrence. With less intensive pre- and post-ECT drug treatment the chances of relapse were increased. CONCLUSIONS. ECT is an effective treatment in the acute phase of a depression. Results after a longer period of follow-up are less satisfactory.

Am J Psychiatry 1998 Feb;155(2):178-83

Two-year outcome of psychotic depression in late life.

Flint AJ, Rifat SL.

Geriatric Psychiatry Program, Toronto Hospital, Ont., Canada. aflint@torhosp.toronto.on.ca

OBJECTIVE: The purpose of this study was to determine whether elderly patients with psychotic depression differed in long-term outcome from patients with nonpsychotic depression.

METHOD: The study group consisted of 19 patients with psychotic major depression who had responded to ECT (N = 15), nortriptyline and perphenazine (N = 2), or nortriptyline, perphenazine, and adjunctive lithium (N = 2) and 68 nonpsychotic depressed patients who had responded to either nortriptyline alone (N = 61) or nortriptyline and lithium (N = 7). All patients were maintained on regimens of full-dose nortriptyline. When prescribed for the index episode, adjunctive lithium was also maintained, but perphenazine was withdrawn 16 weeks after response. Patients were followed on a monthly basis for 2 years or until relapse or recurrence, whichever occurred first.

RESULTS: Patients with psychotic depression had a substantially higher frequency of relapse or recurrence of depression and a shorter time to these events than nonpsychotic depressed patients. At index assessment, patients with psychosis were more severely depressed and had had more prior episodes of depression, but these factors did not account for the difference in outcome between the two groups. Furthermore, before entering the study, none of the psychotic patients had received adequate treatment for the index episode of depression, and so their poor outcome could not be attributed to prior treatment resistance.

CONCLUSIONS: Even when they achieved remission and were maintained on a regimen of full-dose antidepressant medication, older patients with psychotic depression were at greater risk of relapse or recurrence than were their nonpsychotic counterparts. In particular, continuation/maintenance treatment with tricyclic monotherapy following response to ECT had limited efficacy in this group of patients. These findings raise important questions about the optimal treatment of psychotic depression in late life.

J Neurol Neurosurg Psychiatry 1998 Dec;65(6):890-8

Forgetting rates in neuropsychiatric disorders.

Lewis P, Kopelman MD

Division of Psychiatry and Psychology, United Medical and Dental Schools of Guy's and St Thomas's Hospital, St Thomas's Campus, London, UK.

OBJECTIVE: Previous studies have attributed accelerated forgetting rates on recognition memory tasks to temporal lobe pathology, but findings in some patient groups may have been attributable to metabolic disruption. Findings in psychiatric disorders such as schizophrenia are conflicting. The purpose of the present study was to compare forgetting rates in patients with confusional states (post-electroconvulsive therapy (post-ECT), delirium), with those obtained in schizophrenic patients (with putative temporal lobe pathology), non-ECT depressed patients, and healthy controls. The findings could also be compared with previous reports in patients with head injury, focal structural lesions, and Alzheimer's dementia.

METHODS: Two studies employed a picture recognition task to examine forgetting rates, the first between delays of 1 minute, 15 minutes, and 30 minutes, and the second between delays of 10 minutes, 2 hours, and 24 hours.

RESULTS: There were no significant differences in forgetting rates between 1 minute and 30 minutes, but the ECT group showed accelerated forgetting between 10 minutes and 2 hours compared with healthy controls, associated with a rapid decline in "hit rate". This was not attributable to differential changes in either depression or severity of memory impairment. There were no differences in forgetting rates across the other subject groups.

CONCLUSION: Post-ECT confusional state patients (similarly to "within post-traumatic amnesia" patients with head injury) show accelerated forgetting on a recognition memory task and, in this, they contrast with patients who have focal structural lesions or widespread cortical atrophy. Accelerated forgetting may reflect the effect of disrupted cerebral metabolism on either "consolidation" or memory "binding" processes.

PMID: 9854966

Adv Ther 1999 Jan-Feb;16(1):29-38

Time to abandon electroconvulsion as a treatment in modern psychiatry.

Youssef HA, Youssef FA

Medway Hospital, Gillingham, Kent, United Kingdom.

This review examines the evidence for the current use of electroconvulsive therapy (ECT) in psychiatry. The history of ECT is discussed because ECT emerged with no scientific evidence, and the absence of other suitable therapy for psychiatric illness was decisive in its adoption as a treatment. Evidence for the current recommendation of ECT in psychiatry is reconsidered. We suggest that ECT is an unscientific treatment and a symbol of authority of the old psychiatry. ECT is not necessary as a treatment modality in the modern practice of psychiatry.

Publication Types:
Historical article

PMID: 10539092

J Gerontol Nurs 1996 Dec;22(12):14-20

Electroconvulsive therapy and the elderly client.

Brandt B, Ugarriza DN

University of Miami, School of Nursing, Coral Gables, Florida 33124-3850, USA.

ECT should be undertaken only after the outlined treatment protocols have been considered and with the knowledge and understanding of the following statements issued by the United States Department of Health and Human Services in the 1993 Agency for Health Care Policy and Research (AHCPR).

PMID: 9060342

Arch Gen Psychiatry 2000 May;57(5):425-34

A prospective, randomized, double-blind comparison of bilateral and right
unilateral electroconvulsive therapy at different stimulus intensities.

Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, Fitzsimons
L, Moody BJ, Clark J

Department of Biological Psychiatry, New York State Psychiatric Institute, NY
10032, USA. has1@columbia.edu

Note: In this study of two different types of shock therapy with 80 depressed patients, 29% of patients did not respond to treatment, and 53% of the patients who did respond relapsed within two months of treatment. The study was conducted with experimental ECT machines far more powerful than those generally available. The most consistent results were produced by treatment at the highest voltages, well above the seizure threshold. This indicates that ECT's effect is not a result of the seizure, but rather of powerful electric current passing through the brain.

BACKGROUND: Controversy persists about the use of right unilateral (RUL) and bilateral (BL) electroconvulsive therapy (ECT). While RUL ECT results in less severe short-term and long-term cognitive effects, there is concern that it is less efficacious than BL ECT.

METHODS: In a double-blind study, 80 depressed patients were randomized to RULECT, with electrical dosages 50%, 150%, or 500% above the seizure threshold, or BL ECT, with an electrical dosage 150% above the threshold. Depression severity and cognitive functioning were assessed before, during, immediately after, and 2 months after ECT. Compared with baseline, responders had at least a 60% reduction in symptom scores 1 week after ECT, and were monitored for relapse for 1 year.

RESULTS: High-dosage RUL and BL ECT were equivalent in response rate (65%) and approximately twice as effective as low-dosage (35%) or moderate-dosage (30%) unilateral ECT. During the week after the randomized phase, BL ECT resulted in greater impairment than any dosage of unilateral ECT in several measures of anterograde and retrograde memory. Two months after ECT, retrograde amnestic deficits were greatest among patients treated with BL ECT. Thirty-three (53%) of the 62 patients who responded to ECT relapsed, without treatment group differences. The relapse rate was greater in patients who had not responded to adequate pharmacotherapy prior to ECT and who had more severe depressive symptoms after ECT.

CONCLUSION: Right unilateral ECT at high dosage is as effective as a robust form of BL ECT, but produces less severe and persistent cognitive effects.

Publication Types:
Clinical trial
Randomized controlled trial

Comment in:
Arch Gen Psychiatry. 2000 May;57(5):445-6

PMID: 10807482

1: Convuls Ther 1995 Sep;11(3):192-201

Cognitive effects of electroconvulsive therapy: a clinical review for nurses.

Durr AL, Golden RN

Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill 27599, USA.

Cognitive deficits are undesirable effects of electroconvulsive therapy (ECT). This article reviews the cognitive impairments associated with ECT, with an emphasis on linguistic information processing and memory dysfunction. Factors that may have an impact on the cognitive effects of ECT are discussed, along with recommendations for clinical interventions to aid in the treatment of these effects.

Publication Types:
Review
Review, tutorial

PMID: 8528663

JAMA 2001 Mar 14;285(10):1299-307

Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial.

Sackeim HA, Haskett RF, Mulsant BH, Thase ME, Mann JJ, Pettinati HM, Greenberg RM, Crowe RR, Cooper TB, Prudic J Department of Biological Psychiatry, New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA. has1@columbia.edu

CONTEXT: Electroconvulsive therapy (ECT) is highly effective for treatment of major depression, but naturalistic studies show a high rate of relapse after discontinuation of ECT

OBJECTIVE: To determine the efficacy of continuation pharmacotherapy with nortriptyline hydrochloride or combination nortriptyline and lithium carbonate in preventing post-ECT relapse. DESIGN: Randomized, double-blind, placebo-controlled trial conducted from 1993 to 1998, stratified by medication resistance or presence of psychotic depression in the index episode.

SETTING: Two university-based hospitals and 1 private psychiatric hospital.

PATIENTS: Of 290 patients with unipolar major depression recruited through clinical referral who completed an open ECT treatment phase, 159 patients met remitter criteria; 84 remitting patients were eligible and agreed to participate in the continuation study. INTERVENTIONS: Patients were randomly assigned to receive continuation treatment for 24 weeks with placebo (n = 29), nortriptyline (target steady-state level, 75-125 ng/mL) (n = 27), or combination nortriptyline and lithium (target steady-state level, 0.5-0.9 mEq/L) (n = 28).

MAIN OUTCOME MEASURE: Relapse of major depressive episode, compared among the 3 continuation groups. RESULTS: Nortriptyline-lithium combination therapy had a marked advantage in time to relapse, superior to both placebo and nortriptyline alone. Over the 24-week trial, the relapse rate for placebo was 84% (95% confidence interval [CI], 70%-99%); for nortriptyline, 60% (95% CI, 41%-79%); and for nortriptyline-lithium, 39% (95% CI, 19%-59%). All but 1 instance of relapse with nortriptyline-lithium occurred within 5 weeks of ECT termination, while relapse continued throughout treatment with placebo or nortriptyline alone. Medication-resistant patients, female patients, and those with more severe depressive symptoms following ECT had more rapid relapse.

CONCLUSIONS: Our study indicates that without active treatment, virtually all remitted patients relapse within 6 months of stopping ECT. Monotherapy with nortriptyline has limited efficacy. The combination of nortriptyline and lithium is more effective, but the relapse rate is still high, particularly during the first month of continuation therapy.

Publication Types:
Clinical trial
Multicenter study
Randomized controlled trial

Comment in:
JAMA. 2001 Mar 14;285(10):1346-8

PMID: 11255384

J Psychiatry Neurosci 1992 Nov;17(5):191-3

Delayed amnesia and disorientation after electroconvulsive treatment.

Grinshpoon A, Mester R, Spivak B, Berg Y, Bleich A, Weizman A

Ness-Ziona Mental Health Center.

Memory-related effects of electroconvulsive therapy (ECT) are known to appear immediately after the treatment. The case of a 39-year-old woman who underwent a course of ECT because of a recurrent major depressive disorder is described. After a symptom-free period of 48 hours, transient amnesia developed. Her condition appeared to be associated with the electroconvulsive therapy, thereby raising questions about its pathogenicity and management.

PMID: 1489760

Acta Psychiatr Scand 1988 Jun;77(6):654-7

Mortality in a psychiatric population: a Nigerian psychiatric hospital experience.

Abiodun OA

Neuropsychiatric Hospital, Abeokuta, Ogun State, Nigeria.

Out of a total of 10,661 patients admitted over a 10-year period in a Nigerian psychiatric hospital, 138 deaths were recorded. A decreasing trend in the mortality figures was demonstrated despite a marked increase in the number of admissions. There were more male deaths (60%) than female deaths (40%). The majority of the patients who died (64%) were under the age of 40 years. Infection was the single most important cause of death. There was one case of suicide and one other death resulted from ECT. Sudden unexplained deaths occurred in 19% of the cases. Possible ways of further reducing the mortality figures are suggested.

PMID: 3261482

Gen Hosp Psychiatry 1992 May;14(3):204-9

The woman who wanted electroconvulsive therapy and do-not-resuscitate status. Questions of competence on a medical-psychiatry unit.

Sullivan MD, Ward NG, Laxton A

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle 98195.

A case involving an elderly woman suffering concurrently from serious psychiatric and medical illnesses is presented. Ethical considerations concerning her treatment on a medical-psychiatry unit are discussed with special attention to her requests for both electroconvulsive therapy (ECT) and do-not-resuscitate (DNR) status. The compatibility of simultaneous requests for ECT and DNR is examined on three levels. The effect of depression upon competence to request and refuse treatment is analyzed. This case illustrates a conflict between medical and psychiatric treatment goals and ethical traditions which will become more common as psychiatrists treat older and more medically ill patients.

PMID: 1601298

J ECT 2000 Dec;16(4):370-9

Efficacy and cognitive effects of right unilateral electroconvulsive therapy.

Ng C, Schweitzer I, Alexopoulos P, Celi E, Wong L, Tuckwell V, Sergejew A, Tiller J

The Melbourne Clinic, Department of Psychiatry, University of Melbourne, Richmond, Victoria, Australia.

[Medline record in process]

Note: In this study of right unilateral ECT (ECT applied to the right half of the brain only) at 2.5 times the seizure threshold, only 31.2% of patients responded to therapy. There was significant anterograde memory impairment in the short term, although these improved on one-month follow-up. The authors question the efficacy of this type of ECT therapy.

The efficacy, memory, and cognitive effects of right unilateral (RUL) electroconvulsive therapy (ECT) at 2.5 times threshold in 32 inpatients with moderate to severe major depressive disorder were evaluated at baseline, during the course of treatment, and 1 month after treatment. Neuropsychological assessment included the Randt Memory Test, Personal Memory Test, short-version Wechsler Adult Intelligence Scale-Revised, and Self-Rating Scale of Memory Functions. At the treatment end point, although the Hamilton Depression Rating Scale mean score was decreased by 54.2%. the response rate of 2.5 times threshold RUL ECT using stringent criteria was only 31.2%. Treatment was associated with significant anterograde memory impairment in the short term. Mean total scores of the Randt Memory Test and Personal Memory Test were decreased from baseline by 14.8% and 32.5%, respectively, after six sessions of ECT. These memory deficits were significantly improved by the 1 month follow-up examination. Subjective memory scores increased consistently during treatment, correlating with improvements in mood. No adverse effects on nonmemory cognition were found. Although RUL ECT at 2.5 times threshold is not associated with marked or persistent cognitive disturbances, its efficacy may be insufficient in clinical practice.

PMID: 11314875

J Am Geriatr Soc 1990 Jul;38(7):753-8

Electroconvulsive therapy in octogenarians.

Cattan RA, Barry PP, Mead G, Reefe WE, Gay A, Silverman M

Section of Geriatrics, University of Miami School of Medicine, FL 33101.

Note: Patients over 80 years had significantly more cardiovascular complications and falls (95% confidence interval) and tended to have a worse ASA (American Society of Anesthesiologists) scale rating and a somewhat less successful outcome.

Medical records of 81 older patients (65 years of age and over) who underwent electroconvulsive therapy (ECT) at a university-affiliated private geriatric hospital were reviewed to evaluate the safety and efficacy of this treatment for depression in the "young-old" (65 to 80 years) compared with the "old-old" age group (over 80 years), a group that has not yet been adequately studied. Information was obtained regarding demographics, medical and psychiatric diagnosis, medications, indications for ECT, number and laterality of treatments, outcome, and complications. Thirty-nine patients 80+ years of age (mean age, 85 +/- 3.2) were compared with 42 patients 65 to 80 years of age (mean age, 74 +/- 5.2). Statistical analysis was performed using confidence intervals of the difference in proportions of patients in each group. There were no significant differences in the demographics, number and laterality of ECT treatments, indications for ECT treatment, medical diagnosis, medications, or prior history of falls, but psychiatric diagnoses differed slightly. Patients over 80 years had significantly more cardiovascular complications and falls (95% confidence interval) and tended to have a worse ASA (American Society of Anesthesiologists) scale rating and a somewhat less successful outcome. This study confirms the role of ECT as a relatively safe and effective treatment, which may be lifesaving in selected depressed older patients. Prospective studies are needed to understand better the long-term outcome and to prevent the morbidity and mortality associated with ECT in this frail, high-risk older group.

PMID: 2370395

Arch Gen Psychiatry 1976 Sep;33(9):1029-37

Mortality in depressed patients treated with electroconvulsive therapy and antidepressants.

Avery D, Winokur G

Note: This study of mortality among severely depressed patients found no difference in suicide rates among patients receiving shock therapy, antidepressant medication, or neither shock therapy nor antidepressant medication.

The treatments of 519 depressed patients hospitalized from 1959 to 1969 were compared in a three-year follow-up study with particular reference to mortality. The electroconvulsive therapy (ECT) group had a significantly lower mortality than the inadequate antidepressant treatment group (P less than .05) and the group that received neither ECT nor antidepressants (P less than .025). Although the adequate antidepressant treatment group had a low mortality, statistically significant differences between this and other treatment groups could not be documented. Nonsuicidal deaths (P less than .005), and particularly myocardial infarctions (P less than .01), were significantly more frequent in the inadequately treated group compared to the adequately treated group. The superiority of adequate treatment is especially striking among men and among the older age groups. The results underscore the importance of adequate treatment of depression, especially in the older man.

PMID: 962487

J ECT 2000 Dec;16(4):399-408

Treatment and suicide in severe depression: a case-control study of antidepressant therapy at last contact before suicide.

Bradvik L, Berglund M

Department of Clinical Neuroscience, Lund University Hospital, Sweden.

[Medline record in process]

Note: This study compared 89 people with severe depression who committed suicide to a group of 89 similar, severely depressed people who did not commit suicide. The study found no suicide preventive effect for shock therapy. Rather, the study revealed that patients who did not receive continuing drug therapy after shock were far more likely to commit suicide than those who did. The authors emphasize the importance of continuing drug treatment after shock therapy to prevent suicide.

Treatment at last contact in 89 persons with severe depression who committed suicide was compared with treatment at a corresponding date in 89 matched persons who did not commit suicide. No difference in electroconvulsive therapy use or prescription of antidepressant medication could be shown between those who committed suicide and those who did not. Neither was there a difference in response to treatment as measured in rates of improvement with treatment. However, continued treatment with antidepressant medication after electroconvulsive therapy was more common in the persons who did not commit suicide than in those who did (46% versus 13%, p < 0.025). None of the persons who committed suicide who were followed during the 6 months before death had received continued treatment after electroconvulsive therapy. This study lends statistical support to the importance of continuing treatment after electroconvulsive therapy to prevent suicide.

PMID: 11314878

(see also "Electroconvulsive Therapy: A Second Opinion")