Electroconvulsoterapia en el primer episodio de esquizofrenia: impacto en la evolución / Electroconvulsoterapia in the first episode of schizophrenia: impact on evolution

La esquizofrenia es una patología que evolucionade forma crónica, proclive al deterioro, siendo este último variable de acuerdo con comorbilidades presentes y adherencia al tratamiento integral. Genera alteraciones cognitivas e influye negativamente en el desempeño de quienes la padecen, causando detrimento global de los pragmatismos. La electroconvulsoterapia es una opción terapéutica ampliamente utilizada en nuestro país para tratar sintomatología del humor y episodios psicóticos agudos, entre otros. En la actualidad se sabe que la detección e intervención precoz de un episodio psicótico agudo —el cual puede corresponder al primer episodio psicótico de esquizofrenia —mejora el pronóstico a largo plazo. El objetivo es demostrar si existe un vínculo entre la indicación de electroconvulsoterapia durante el primer episodio psicótico de esquizofrenia y la duración del intervalo libre de internación. Este es un estudio de tipo analítico, observacional, retrospectivo (cohorte histórica) que busca aumentar las evidencias en este amplio campo de investigación. Observamos que el tiempo libre de internación luego de la primera hospitalización no tuvo relación con el hecho de si recibieron electroconvulsoterapia o no; sin embargo, al realizar el análisis de potencia estadístico surge que los resultados no son concluyentes. Se destaca el importante porcentaje de patología dual en este grupo de usuarios: un 39%.

Schizophrenia is a chronic disease, prone todeterioration, the latter being variable accordingto comorbidities and treatment adherence. It generates cognitive impairment and adverselyaffects overall performance, causing deterioration of pragmatisms. Electroconvulsive therapy is awidely used therapeutic option in our countryfor acute affective and psychotic episodes. It iswell known that early detection and interventionof an acute psychotic episode —which maycorrespond to the first psychotic episode of schizophrenia— improves long-term prognosis.This study intended to show whether there is alink between early indication of electroconvulsive therapy during the first episode and timeto relapse and hospital readmission. This is ananalytical, observational, retrospective (historical cohort) study, which aims to increase theevidence in this broad research field. As a resultthere was no link between time to relapse and electro convulsive therapy in the first episode; nevertheless after a post hoc analysis resultsare not conclusive. Dual diagnosis stands outin this group and corresponds to 39%.

Eletroconvulsoterapia na depressão maior: aspectos atuais / Electroconvulsive therapy in major depression: current aspects

Objetivo: A eficácia da eletroconvulsoterapia em tratar sintomas depressivos está estabelecida por meio de inúmeros estudos desenvolvidos durante as últimas décadas. A eletroconvulsoterapia é o tratamento biológico mais efetivo para depressão atualmente disponível. O objetivo deste estudo foi demonstrar o papel da eletroconvulsoterapia no tratamento da depressão e destacar aspectos atuais relativos à sua prática. Método: Foram revisados na literatura estudos de eficácia, remissão de sintomas, fatores preditores de resposta, assim como aspectos atuais acerca da qualidade de vida, percepção dos pacientes, mecanismo de ação, técnica e prejuízo cognitivos. Resultados: Os principais achados desta revisão foram: 1) a eletroconvulsoterapia é mais efetiva do que qualquer medicação antidepressiva; 2) a remissão da depressão com a eletroconvulsoterapia varia, em geral, de 50 a 80%; 3) Ainda é controverso o efeito da eletroconvulsoterapia nos níveis de fator neurotrófico derivado do cérebro (acho que aqui pode colocar entre parenteses o “BNDF”); 4) a eletroconvulsoterapia tem efeito positivo na melhora da qualidade de vida; 5) os pacientes submetidos à eletroconvulsoterapia, em geral, têm uma percepção positiva do tratamento. Conclusão: A eletroconvulsoterapia permanece sendo um tratamento altamente eficaz em pacientes com depressão resistente. Com o avanço da sua técnica, a eletroconvulsoterapia tornou-se um procedimento aindamais seguro e útil tanto para a fase aguda, quanto para a prevenção de novos episódios depressivos.

Objective: The efficacy of electroconvulsive therapy in treating depressive symptoms has been established by means of innumerablestudies developed along the last decades. Electroconvulsive therapy is the most effective biological treatment for depression currently available. The objective of this study was to demonstrate the role of lectroconvulsive therapy in the treatment of depression and highlight present aspects related to its practice. Method: We reviewed in the literature studies on efficacy, symptom remission, predictive response factors as well as current aspects regarding quality of life, the patients’ perception, mechanism of action, technique and cognitive impairment. Results: The main results found in the this revision were: 1) electroconvulsive therapy is more effective than any antidepressant medication; 2) the remission of depression with electroconvulsive therapy varies, in general, from 50 to 80%; 3) The effect of electroconvulsive therapy in brain-derived neurotrophic factor levels is still controversial; 4) electroconvulsive therapy has a positive effect in the improvement of quality of life; 5) patients submitted to electroconvulsive therapy have, in general, a positive perception about the treatment. Conclusion: Electroconvulsive therapy remains a highly efficacious treatment in treatment-resistant depression. With the improvement of its technique, electroconvulsive therapy has become an even safer and more useful procedure both for the acute phase and for the prevention of new depressive episodes.

WPA position statement on the ethics of the use of unmodified electroconvulsive therapy

This position statement is an addendum to the one on the use and safety of electroconvulsive therapy that was prepared by the Section of Biological Psychiatry in 2004 and was eventually approved by the WPA General Assembly in 2005

Repeated electroconvulsive seizure induces c-Myc down-regulation and Bad inactivation in the rat frontal cortex

Repeated electroconvulsive seizure (ECS), a model for electroconvulsive therapy (ECT), exerts neuroprotective and proliferative effects in the brain. This trophic action of ECS requires inhibition of apoptotic activity, in addition to activation of survival signals. c-Myc plays an important role in apoptosis of neurons, in cooperation with the Bcl-2 family proteins, and its activity and stability are regulated by phosphorylation and ubiquitination. We examined c-Myc and related proteins responsible for apoptosis after repeated ECS. In the rat frontal cortex, repeated ECS for 10 days reduced the total amount of c-Myc, while increasing phosphorylation of c-Myc at Thr58, which reportedly induces degradation of c-Myc. As expected, ubiquitination of both phosphorylated and total c-Myc increased after 10 days ECS, suggesting that ECS may reduce c-Myc protein level via ubiquitination-proteasomal degradation. Bcl-2 family proteins, caspase, and poly(ADP-ribose) polymerase (PARP) were investigated to determine the consequence of down-regulating c-Myc. Protein levels of Bcl-2, Bcl-X(L), Bax, and Bad showed no change, and cleavage of caspase-3 and PARP were not induced. However, phosphorylation of Bad at Ser-155 and binding of Bad to 14-3-3 increased without binding to Bcl-X(L) after repeated ECS, implying that repeated ECS sequesters apoptotic Bad and frees pro-survival Bcl-X(L). Taken together, c-Myc down-regulation via ubiquitination-proteasomal degradation and Bad inactivation by binding to 14-3-3 may be anti-apoptotic mechanisms elicited by repeated ECS in the rat frontal cortex. This finding further supports the trophic effect of ECS blocking apoptosis as a possible therapeutic effect of ECT.

Voices of people who have received ECT.

Electroconvulsive therapy (ECT) is controversial but widely practised in India. We elicited perspectives, using qualitative interviews, from patients who received ECT and their relatives. Ethical issues related to personal autonomy, right to information, competence, informed consent and consent by proxy are discussed. We suggest strategies to ensure a basic minimum standard for obtaining informed consent for ECT in India.

Assessment of the cardiovascular effects of electroconvulsive therapy in individuals older than 50 years

To evaluate the impact of electroconvulsive therapy on arterial blood pressure, heart rate, heart rate variability, and the occurrence of ischemia or arrhythmias, 38 (18 men) depressive patients free from systemic diseases, 50 to 83 years old (mean: 64.7 ± 8.6) underwent electroconvulsive therapy. All patients were studied with simultaneous 24-h ambulatory blood pressure and Holter monitoring, starting 18 h before and continuing for 3 h after electroconvulsive therapy. Blood pressure, heart rate, heart rate variability, arrhythmias, and ischemic episodes were recorded. Before each session of electroconvulsive therapy, blood pressure and heart rate were in the normal range; supraventricular ectopic beats occurred in all patients and ventricular ectopic beats in 27/38; 2 patients had non-sustained ventricular tachycardia. After shock, systolic, mean and diastolic blood pressure increased 29, 25, and 24 percent (P < 0.001), respectively, and returned to baseline values within 1 h. Maximum, mean and minimum heart rate increased 56, 52, and 49 percent (P < 0.001), respectively, followed by a significant decrease within 5 min; heart rate gradually increased again thereafter and remained elevated for 1 h. Analysis of heart rate variability showed increased sympathetic activity during shock with a decrease in both sympathetic and parasympathetic drive afterwards. No serious adverse effects occurred; electroconvulsive therapy did not trigger any malignant arrhythmias or ischemia. In middle-aged and elderly people free from systemic diseases, electroconvulsive therapy caused transitory increases in blood pressure and heart rate and a decrease in heart rate variability but these changes were not associated with serious adverse clinical events.

Comparação entre a resposta antidepressiva à terapia farmacológica e a estimulação magnetica transcraniana de repetição em pacientes com doença de Parkinson / Comparison between rapid-rate transcranial magnetic stimulation and fluoxetine in depressed patients with Parkinson's disease: a randomized trial

A depressão na doença de Parkinson (DP) tem grande prevalência. Devido as dificuldades de tratamento desse distúrbio, a estimulação magnética transcraniana (EMT) é uma técnica indolor que pode ser usada como tratamento alternativo. Para avaliar o efeito antidepressivo da EMT, 42 pacientes com DP e depressão foram divididos aleatoriamente em dois grupos de tratamento: um grupo recebeu EMT ativa e medicação placebo, e o outro recebeu EMT placebo e fluoxetina. Os resultados sugerem que a EMT apresenta a mesma eficácia antidepressiva quando comparada à fluoxetina, porém com a vantagem de ter um possível efeito terapêutico discreto na função motora e cognitiva com menos efeitos adversos. /Depression is the most common psychiatric problem in Parkinson disease (PD) and it is difficult to be treated. Transcranial magnetic stimulation (TMS) is a non-invasive method to stimulate the brain and can be used to depression treatment. The present study aims to investigate the efficacy of 15Hz TMS in Parkinson disease patients with depression. Forty-two patients were enrolled into 2 groups, one received active TMS and placebo medication and the other sham TMS and fluoxetine 20mg/day...

Subarachnoid haemorrhage following electroconvulsive therapy

Subarachnoid haemorrhage is an uncommon reported complication of electroconvulsive therapy [ECT]. To our knowledge, there has been no reported case in Iraq. Herewith is a case report of this complication following ECT. The patient is a 40 year Iraqi hypertensive female, who had chronic recurrent headaches for 5 years and was given an ECT session as a treatment for a possible underlying depression. The diagnosis of subarachnoid haemorrhage was confirmed by CT scan of the brain and lumbar puncture. The patient was treated conservatively and achieved a satisfactory improvement

Estimulação magnética transcraniana de repetição: comparação da eficácia com a eletroconvulsoterapia / Repetitive transcranial magnetic stimulation: comparison of efficacy with electroconvulsive therapy

Os estudos publicados nos últimos anos sobre a utilização da estimulação magnética transcraniana de repetição (EMTr) têm sugerido significativas ações antidepressivas. Neste trabalho foi realizado um estudo comparativo da EMTr com a eletroconvulsoterapia (ECT) que é um método consagrado para o tratamento de transtornos depressivos. Foi feita, em primeiro lugar, uma extensa revisão a respeito destes dois métodos de tratamento não medicamentoso, expondo a sua história, a sua eficácia, as principais indicações, contra-indicações e efeitos colaterais, além dos possíveis mecanismos de ação, que ainda não estão completamente esclarecidos. A seguir foi realizado um ensaio clínico controlado, randomizado, simples-cego, comparando a eficácia de ambos para o tratamento da Depressão Maior unipolar refratária, sem sintomas psicóticos, com indicação de ECT. Também foi realizada uma avaliação dos efeitos cognitivos, especialmente da memória. Trinta e cinco pacientes foram incluídos. A eletroconvulsoterapia foi realizada com indução anestésica geral e relaxamento muscular. Foram feitas aplicações na posição unilateral direita com carga 4,5 vezes o limiar convulsígeno. A EMTr foi aplicada no córtex pré-frontal dorso-lateral esquerdo com intensidade de 100% do limiar motor. Os pacientes receberam 20 sessões (cinco dias por semana por quatro semanas), com 25 séries de estimulação por dia (com freqüência de 10 Hz por 10 segundos, com intervalos de 20 segundos). As escalas de avaliação foram aplicadas nos tempos basal, após duas semanas de tratamento e após quatro semanas de tratamento. Ambos os tratamentos tiveram eficácia equivalente, com uma taxa de redução média dos escores na escala de Hamilton para depressão de 42 %, uma resposta clínica de 46 % e uma taxa de remissão de 14%. A EMTr apresentou um perfil mais benigno de efeitos colaterais (cefaléia em 1 %). A ECT resultou em cefaléia (em 20 %) e náuseas (em 10%).Não houve diferença nos efeitos cognitivos...

Studies published over the past few years suggest that repetitive transcranial magnetic stimulation (rTMS) may have significant antidepressant actions. This work performs a comparison between rTMS and electroconvulsive therapy (ECT), an established method to treat depression disorders. First there was an extensive review on the knowledge of both non pharmacological treatments including their history, efficacy, main indications, contraindications and side effects, in addition to the possible mechanisms of action, not yet fully understood. After that, a controlled randomized, single-blind clinical trial was conducted, comparing the efficacy to treat unipolar resistant nonpsychotic major depression that were referred to receive ECT. An evaluation of cognitive effects was also performed, specially memory effects. Thirty five patients were included. Electroconvulsive therapy was performed with general anesthesia and muscular relaxation. Right unilateral electrodes positioning was used, with a charge 4.5 times the convulsive threshold. rTMS was performed over the left dorsolateral prefrontal cortex at 100% motor threshold. Patients were treated with 20 sessions (five times per week for four weeks) with 25 trains a day (frequency of 10 Hz, duration of 10 seconds with 20 seconds intertrain interval). Patients were evaluated at baseline, after two weeks and after four weeks of either treatment. Both groups were equivalent in efficacy, showing a means of reduction on Hamilton depression rating scale of 42%, an overall clinical response of 46% and a remission rate of 14%. rTMS showed a more benign profile regarding side effects (headache on 1%). ECT induced headache (20%) and nausea (10%). No cognitive effects were observed on either treatments. This study adds to the growing literature supporting an antidepressant effect for rTMS, similar to ECT on patients with unipolar nonpsychotic major depression.

Estimulação magnética transcraniana de repetição: comparação da eficácia com eletroconvulsoterapia / Repetitive transcranial magnetic stimulation: comparison of efficacy with electroconvulsoterapy

Os estudos publicados nos últimos anos sobre a utilização da estimulação magnética transcraniana de repetição (EMTr) têm sugerido significativas ações antidepressivas. Neste trabalho foi realizado um estudo comparativo da EMTr com a eletroconvulsoterapia (ECT) que é um método consagrado para o tratamento de transtornos depressivos. Foi feita, em primeiro lugar, uma extensa revisão a respeito destes dois métodos de tratamento não medicamentoso, expondo a sua história, a sua eficácia, as principais indicações, contra-indicações e efeitos colaterais / Studies published over the past few years suggest that repetitive transcranial magnetic stimulation (rTMS) may have significant antidepressant actions. This work performs a comparison between rTMS and electroconvulsive therapy (ECT), an established method to treat depression disorders. First there was an extensive review on the knowledge of both non pharmacological treatments including their history, efficacy, main indications, contraindications and side effects, in addition to the possible mechanisms of action, not yet fully understood. After that, a controlled randomized, single-blind clinical trial was conducted, comparing the efficacy to treat unipolar resistant nonpsychotic major depression that were referred to receive ECT. An evaluation of cognitive effects was also performed, specially memory effects. Thirty five patients were included. Electroconvulsive therapy was performed with general anesthesia and muscular relaxation. Right unilateral electrodes positioning was used, with a charge 4.5 times the convulsive threshold. rTMS was performed over the left...

Seizure threshold in electroconvulsive therapy: III. A long-term study.

There has been a dearth of long-term studies investigating the seizure-threshold changes in patients receiving electroconvulsive therapy (ECT). This study aimed to determine changes in seizure threshold over acute, continuation, and maintenance ECT (Phases I, II, and III). Twenty schizophrenic patients were estimated to have a seizure threshold by the dose-titration method. All patients had a rise in seizure threshold at the end of Phase I with 185 +/- 196 per cent increments. Ten patients had a further threshold-increase at the sixth month (Phase II, n = 20), and four at the twelfth month (Phase III, n = 14). The overall threshold-increases of Phases II and III were 370 +/- 342 per cent and 416 +/- 427 per cent, respectively. Seizure-threshold increases were robust during acute ECT, and tended to reach a plateau over the continuation and maintenance phases.

Seizure threshold in ECT: I. Initial seizure threshold.

Seizure threshold determination is of crucial importance in optimizing electrical stimulus dosage during administering electroconvulsive therapy (ECT). We measured initial seizure threshold by means of Srinakharinwirot University titration schedule in 150 psychotic patients. Initial seizure threshold was approximately 104 millicoulombs on average, but varied widely (12-fold) across patients. Motor seizure duration was inversely related to initial seizure threshold. Seizure threshold could be strongly predicted by age. The results may have important clinical implications for stimulus dosing strategy in ECT.

Seizure threshold in ECT: II. Dose titration vs age and half age methods.

Seizure threshold determination is of crucial importance in optimizing electrical stimulus dosage at electroconvulsive therapy (ECT). We measured initial seizure threshold by means of Srinakharinwirot University titration schedule in 106 patients with schizophrenia or schizoaffective disorder, receiving bilateral ECT. Seizure threshold was approximately 106 millicoulombs on average, and varied 5-fold across patients. Seizure threshold was directly related to age, but inversely related to motor seizure duration. Comparisons of stimulus charge were done with the Age and Half age methods. By using the Half age method, 68 per cent of patients would have seized at the first stimulation and resulted in a closer mean charge to dose-titration method than the Age method. The results may have important clinical implications for stimulus dosing strategy in ECT.