A survey of the practice of electroconvulsive therapy in Asia.

OBJECTIVE: To describe a comprehensive survey of the practice of electroconvulsive therapy (ECT) in Asia. METHOD: Between 2001 and 2003, a 29-item questionnaire was sent to 977 psychiatric facilities in 45 Asian countries. RESULTS: Completed questionnaires were returned by 334 (34.2%) institutions in 29 (64.4%) countries. Electroconvulsive therapy was available in 257 institutions in 23 countries. During the year before the survey, 39,875 patients (62% men) received a mean of 7.1 ECT treatments. Most patients (73.1%) were 18 to 44 years old; few were younger than 18 years (6.0%) or older than 64 years (4.4%). Indications for ECT were schizophrenia (41.8%), major depression (32.4%), mania (14.0%), catatonia (6.9%), drug abuse (1.8%), dysthymia (1.6%), and others. Brief-pulse ECT devices were used in only 115 (58.4%) of 197 institutions. Routine electroencephalographic monitoring was conducted in only 59 (23.0%) institutions. Bilateral electrode placement was invariable in 202 (78.6%) institutions. Unmodified ECT was administered to 22,194 (55.7%) patients at 141 (54.9%) institutions in 14 countries. Continuation ECT was available in only 115 (44.7%) institutions in 17 countries. No institution had a formal ECT training program. CONCLUSIONS: The practice of ECT in Asia may seem suboptimal: schizophrenia, not depression, is the most common indication; most institutions offer sine-wave ECT; unmodified ECT is commonly administered; bilateral electrode placement is invariable in most institutions; electroencephalographic monitoring is uncommon; continuation ECT is infrequent; and no formal training in ECT is available. We speculate that the suboptimal practices reflect felt needs and ground realities in standards of medical care in developing countries rather than a misuse of ECT.

Use of the Neuro-Wrap system for severe post-electroconvulsive therapy headaches.

OBJECTIVE: To determine, in a nonblinded trial, if the Neuro-Wrap system is effective in reducing the severity of pain in patients with severe post-electroconvulsive therapy (ECT) headaches not adequately responsive to routine analgesic treatment. BACKGROUND: A very troubling side effect of ECT is severe post-ECT headaches. Although these headaches usually respond to routine analgesic medication, some patients continue to experience severe headache despite treatment. This very unpleasant sensation, repeated with each ECT, may cause patients to prematurely stop ECT and experience a relapse in their psychiatric symptoms. "Cold therapy" has been used for a long time as an adjunct to treat headache and pain. The Neuro-Wrap system is a method to provide temperature-controlled cooling to the head without the need to frequently reapply ice packs or physically hold the ice packs in position. It has been used successfully for patients with migraine headaches. This is the first report of its use with patients experiencing severe post-ECT headaches. METHODS: The study comprised a total of 14 patients receiving ECT who experienced a severe headache for 2 successive ECT treatments or 2 of their last 4 treatments and who had only partial or no response to usual analgesic treatment for their headache. After completion of the ECT, the Neuro-Wrap was placed on the head of the patient for a maximum of 40 minutes. Patients continued to receive analgesic medication as needed for relief of headache pain. Patients were their own control group. RESULTS: A total of 85 Neuro-Wrap treatments were given to 14 patients ranging in age from 23 to 71 years old. Nine patients reported clearly positive results on 67 different occasions. Three reported mild alleviation of headaches on 15 occasions. The remaining 2 patients had a total of 3 treatments with no benefit. After the initial treatment, 12 of 14 patients wanted to use the machine after all their subsequent ECT sessions. CONCLUSIONS: Cold therapy with Neuro-Wrap is an effective alternative treatment for refractory headaches caused by ECT.

ECT practice in Japan.

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

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

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

Electroconvulsive therapy practice in Thailand.

OBJECTIVES: To obtain an overview of electroconvulsive therapy (ECT) practice in Thailand. METHODS: Questionnaires were sent to all institutions providing psychiatric care; data were collected from September 1, 2001, to August 31, 2002. RESULTS: Fifty-three responses were received from 67 institutions (79.1%). ECT is available in 26 hospitals. Approximately 6,914 patients received 51,565 ECT treatments, of which, 6,469 patients (93.56%) received 48,240 treatments (93.55%) in the psychiatric hospitals. The ECT utilization rate was 11.15 patients treated per 100,000. Twelve institutions used MECTA (Spectrum or SR1) or Thymatron DGx. Bilateral ECT was used exclusively in all institutions. In 2 medical schools, all patients received double ECT throughout their treatment courses. Unmodified ECT was always used in nine psychiatric hospitals and five general hospitals, and occasionally used in 2 university hospitals comprising 94.2% of all ECT usage. Patients with schizophrenia most frequently received ECT (74%), followed by mania (8%) and major depression (7%). The nurse alone administered ECT in four psychiatric hospitals. Although the death rate was estimated at 0.08%, there was no ECT-related death during the survey period. Continuation ECT was performed in 11 and maintenance ECT in 6 institutions. Five institutions had acceptable training programs for psychiatry residents but none had training syllabus, 2 institutions had teaching schedule for medical students. CONCLUSIONS: ECT use in Thailand is high. Nearly all ECTs (93.6%) were performed in the psychiatric hospital and 94.2% of all treatments were unmodified ECT. Lacking of proper training in ECT is evident.

Transcutaneous acupoint electrical stimulation in preventing and treating nausea and vomiting in patients receiving electroconvulsive therapy.

A significant number of patients complain of nausea after general anesthesia and electroconvulsive therapy (ECT). Nausea is second only to headache as the most frequent and troublesome systemic side effect of ECT. The most common treatment of this is antiemetic drugs. Transcutaneous acupoint electrical stimulation (TAES) is a nonpharmacologic method for preventing and treating nausea and vomiting. TAES can alleviate motion sickness, reduce the incidence of vomiting caused by chemotherapy, and treat pregnancy-induced nausea and vomiting. TAES has been shown to reduce the incidence of postoperative nausea after general anesthesia. This is the first report to review the effectiveness of TAES in preventing and treating nausea and vomiting in 11 patients receiving ECT. Nine of these patients had a good response to TAES. One patient had a mixed response, and 1 did not respond to TAES.

Acute and maintenance ECT with flupenthixol in refractory schizophrenia: sustained improvements in psychopathology, quality of life, and social outcomes.

OBJECTIVE: To determine the effects of ECT combined with antipsychotic medication therapy on psychopathology, quality of life, and social functioning in patients with refractory schizophrenia. METHOD: An open acute (Phase I) and maintenance (Phase II) study of the combination of ECT and flupenthixol in the treatment of 46 schizophrenic patients who were nonresponsive to antipsychotic medication from at least two different classes. Scales used: the Brief Psychiatric Rating Scale (BPRS), the Quality of Life Scale (QLS), Social and Occupational Functioning Assessment Scale (SOFAS), Global Assessment of Functioning (GAF), and Mini-Mental State Exam (MMSE). The duration of Phase II was 1 year. RESULTS: In Phase I, there were marked reductions in the BPRS scores, and substantial increases in the QLS, SOFAS, GAF, and MMSE scores. During Phase II, the BPRS negative symptoms worsened but remained improved from baseline. Changes in other outcome measures were negligible. CONCLUSION: ECT and MECT combined with flupenthixol were effective in improving psychopathology in patients refractory to antipsychotic medication alone. Ratings of psychopathology, quality of life, and social functioning all improved in Phase I and were generally sustained during Phase II in patients who had remitted.

Anticholinergics and ECT.

Anticholinergic medication is commonly used prior to anesthetizing patients for electroconvulsive therapy (ECT). Its routine use is the subject of ongoing controversy. This article reviews how anticholinergics came to be used with ECT and the work supporting or refuting their routine use. The route of administration and their use with beta blockers are reviewed. Atropine, glycopyrrolate, and scopolamine are compared. While acknowledging the pau-city of carefully controlled trials with large numbers of patients, the routine use of intravenous atropine prior to administering ECT is recommended unless specifically contraindicated.

Atypical Cholinesterase and Prolonged Apnea During Electroconvulsive Therapy.

A 62-year-old man developed prolonged apnea during ECT with succinylcholine. He was found to have atypical cholinesterase. Subsequent ECTs were given using atracurium as the muscle relaxant. A review of the finding of atypical cholinesterase is presented along with a discussion of the use of atracurium.

A Survey of ECT Use in Asia.

A questionnaire was mailed to 100 hospitals involved with medical education in 13 Asian countries. Replies were received from 36. The authors compare electroconvulsive therapy (ECT) usage in Asian countries with that in the United States. Marked similarities occur in response rate, number of treatments, and treatment techniques. Differences in anesthesia are associated with a seemingly higher incidence of injury. Bilateral electrode placement and maintenance ECT are widely used.

Maintenance Electroconvulsive Therapy in Clinical Practice.

Five cases of maintenance electroconvulsive therapy (ECT) are reviewed to illustrate the indications for this treatment. The patients' conditions described are consistent with the recommendations of the 1990 American Psychiatric Association Task Force on ECT. Guidelines and examples for selecting patients for maintenance ECT are presented, but when to preferentially treat with continuation pharmacotherapy versus ECT requires further study. Optimal dosing, interval between treatments, and duration of treatment remain questions. The logistics of the treatment are briefly presented and should be easily incorporated into most ECT programs.

Maintenance ECT: A Survey of Practice (1986).

A questionnaire on the use of maintenance or continuation ECT was mailed to 173 practitioners of ECT. Of 86 respondents, 51 reported they used maintenance therapy, and 35 did not. Users came from 24 states, with five states accounting for more than half. Of practitioners giving maintenance ECT, each treated a median of three patients annually between 1981 through 1984, with a range from zero to "thousands." Frequency of treatments is determined empirically, with most treatments given monthly. Memory impairment is the most commonly cited risk. Depression is the diagnosis in 90% of the patients, with schizoaffective, schizophrenic, and manic patients equally comprising the remainder of the patients. The longest series reported for any one patient is 2,400 treatments.

Practice Patterns of Electroconvulsive Therapy: A California Perspective (1984).

The sixty-five California hospitals administering electroconvulsive therapy (ECT) during 1984 were surveyed regarding ECT practices to develop data on the community standard of care. Usable data were obtained from 58 hospitals. In each facility two psychiatrists usually administered ECT, including one psychiatrist who received credentials in or after 1977. Thirty-four brief-pulse and 43 sine-wave machines were in use. Treatment was performed on the psychiatric unit in 41.4% of the hospitals, in the operating room or the recovery room in 50% of the hospitals, and in other locations in 8.6% of the hospitals. The psychiatrist administered the anesthesia in 12 (21%) of the hospitals. Unilateral electrode placement was used in 42% of patients. The use of anesthetic agents, ancillary equipment, and staffing patterns is reviewed.