Generalized Periodic Discharges Associated With Catatonia and Delirium: A Case Series.

OBJECTIVE: Generalized periodic discharges are a repeated and generalized electroencephalography (EEG) pattern that can be seen in the context of altered mental status. This article describes a series of five individuals with generalized periodic discharges who demonstrated signs and symptoms of catatonia, a treatable neuropsychiatric condition. METHODS: Inpatients with a clinical diagnosis of catatonia, determined with the Bush-Francis Catatonia Rating Scale (BFCRS), and EEG recordings with generalized periodic discharges were analyzed in a retrospective case series. RESULTS: Five patients with catatonia and generalized periodic discharges on EEG were evaluated from among 106 patients with catatonia and contemporaneous EEG measurements. Four of these patients showed an improvement in catatonia severity when treated with benzodiazepines, with an average reduction of 6.75 points on the BFCRS. CONCLUSIONS: Among patients with generalized periodic discharges, catatonia should be considered, in the appropriate clinical context. Patients with generalized periodic discharges and catatonia may benefit from treatment with empiric trials of benzodiazepines.

Diagnostic features of paediatric catatonia: multisite retrospective cohort study.

BACKGROUND: Catatonia is a neuropsychiatric disorder characterised by psychomotor changes that can affect individuals across the lifespan. Although features of catatonia have been described in adults, the most common clinical symptoms among paediatric patients with catatonia are not well characterised. AIMS: The goal of this study was to characterise the symptoms of catatonia demonstrated by paediatric patients, and to explore demographic and diagnostic factors associated with greater catatonia severity. METHOD: We conducted a multicentre retrospective cohort study, from 1 January 2018 to 6 January 2023, of patients aged 18 and younger with a clinical diagnosis of catatonia and symptom assessment using the Bush Francis Catatonia Rating Scale (BFCRS). RESULTS: A total of 143 patients met inclusion criteria. The median age was 15 (interquartile range: 13-16) years and 66 (46.2%) patients were female. Neurodevelopmental disabilities were present in 55 (38.5%) patients. Patients demonstrated a mean of 6.0 ± 2.1 signs of catatonia on the Bush Francis Catatonia Screening Item, with a mean BFCRS score of 15.0 ± 5.9. Among the 23 items of the BFCRS, six were present in >50% of patients (staring, mutism, immobility/stupor, withdrawal, posturing/catalepsy, rigidity), and four were present in <20% of cases (waxy flexibility, mitgehen, gegenhalten, grasp reflex). In an adjusted model, patients with neurodevelopmental disorders demonstrated greater BFCRS severity than those with other diagnoses. CONCLUSIONS: Catatonia was diagnosed in a range of mental health conditions. Further research is needed to define optimal diagnostic criteria for catatonia in paediatric patients, and clarify the clinical course of the disorder.

Pediatric Physical Restraint Coding in US Hospitals: A 2019 Kids Inpatient Database Study.

BACKGROUND: Reduction of physical restraint utilization is a goal of high-quality hospital care, but there is little nationally-representative data about physical restraint utilization in hospitalized children in the United States. This study reports the rate of physical restraint coding among hospitalizations for patients aged 1 to 18 years old in the United States and explores associated demographic and diagnostic factors. METHODS: The Kids' Inpatient Database, an all-payors database of community hospital discharges in the United States, was queried for hospitalizations with a diagnosis of physical restraint status in 2019. Logistic regression using patient sociodemographic characteristics was used to characterize factors associated with physical restraint coding. RESULTS: A coded diagnosis of physical restraint status was present for 8893 (95% confidence interval [CI]: 8227-9560) hospitalizations among individuals aged 1 to 18 years old, or 0.63% of hospitalizations. Diagnoses associated with physical restraint varied by age, with mental health diagnoses overall the most frequent in an adjusted model, male sex (adjusted odds ratio [aOR] 1.56; 95% CI: 1.47-1.65), Black race (aOR 1.43; 95% CI: 1.33-1.55), a primary mental health or substance diagnosis (aOR 7.13; 95% CI: 6.42-7.90), Medicare or Medicaid insurance (aOR 1.33; 95% CI: 1.24-1.43), and more severe illness (aOR 2.83; 95% CI: 2.73-2.94) were associated with higher odds of a hospitalization involving a physical restraint code. CONCLUSIONS: Physical restraint coding varied by age, sex, race, region, and disease severity. These results highlight potential disparities in physical restraint utilization, which may have consequences for equity.

Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System.

Since 2007, the Medicare Severity Diagnosis Related Groups classification system has favored billing codes for acute encephalopathy over delirium codes in determining hospital reimbursement and several quality-of-care value metrics, despite broad overlap between these sets of diagnostic codes. Toxic and metabolic encephalopathy codes are designated as major complication or comorbidity, whereas causally specified delirium codes are designated as complication or comorbidity and thus associated with a lower reimbursement and lesser impact on value metrics. The authors led a submission to the U.S. Centers for Medicare and Medicaid Services requesting that causally specified delirium be designated major complication or comorbidity alongside toxic and metabolic encephalopathy. Delirium warrants reclassification because it satisfies U.S. Centers for Medicare and Medicaid Services' guiding principles for re-evaluating Medicare Severity Diagnosis Related Group severity levels. Delirium: (1) has a bidirectional relationship with the permanent condition of dementia (major neurocognitive disorder per DSM-5-TR), (2) indexes vulnerability across populations, (3) impacts healthcare systems across levels of care, (4) complicates postoperative recovery, (5) consigns patients to higher levels of care, (6) impedes patient engagement in care, (7) has several recent treatment guidelines, (8) often indicates neuronal/brain injury, and (9) represents a common expression of terminal illness. The proposal's impact was explored using the 2019 National Inpatient Sample, which suggested that increasing delirium's complexity designation would lead to an upcoding of less than 1% of eligible discharges. Parity for delirium is essential to enhancing awareness of delirium's clinical and economic costs. Appreciating delirium's impact would encourage delirium prevention and screening efforts, thereby mitigating its dire outcomes for patients, families, and healthcare systems.

Symptoms of Catatonia Observed in Down Syndrome Regressive Disorder: A Retrospective Analysis.

PURPOSE: Down Syndrome Regressive Disorder (DSRD) is a neuropsychiatric condition associated with severe symptomology and a negative impact on quality of life. DSRD frequently presents with catatonic symptoms. However, few studies have reported the specific catatonic symptoms that occur in DSRD. METHODS: We conducted a retrospective analysis of medical records in a large health system in the southern United States to identify patients with diagnoses of DS with catatonic symptoms who presented for clinical care between 1/1/2018 and 12/1/2023. Patients were included in the study if they had a diagnosis of DSRD or met the criteria for DSRD using consensus guidelines on retrospective chart review, and catatonia as confirmed in clinical documentation and had a full Bush Francis Catatonia Rating Scale (BFCRS) documented at the time of initial catatonia diagnosis. RESULTS: A total of nine patients who met the criteria for DSRD and catatonia using the BFCRS were identified. The average age of patients at the time of DSRD diagnosis was 21.1 years (SD = 13.87). The mean BFCRS score on initial evaluation was 17.3 (SD = 7.0) and the mean number of positive catatonia signs was 11.1 (SD = 1.5). Staring was present in all cases (n = 9, 100%), followed by mutism, grimacing, and rigidity (n = 7, 77.9%). CONCLUSIONS: In a sample of nine patients with DSRD, all patients were diagnosed with catatonia. Catatonia is severe if undiagnosed and untreated. Future research is needed to assess specific symptoms of catatonia in DSRD, and longitudinal outcomes to assess optimal means of treatment.

Use of ECT for Children With and Without Catatonia: A Single-Site Retrospective Analysis.

OBJECTIVES: The objective study was to investigate the safety and efficacy of electroconvulsive therapy (ECT) in a retrospective cohort of pediatric patients. METHODS: A single-site retrospective analysis was conducted of patients aged younger than 18 years who received ECT in a private university hospital from January 28, 2012 to April 8, 2023. Treatment efficacy and adverse events were determined retrospectively through review of the medical record. RESULTS: A total of 36 pediatric patients met the inclusion criteria. Catatonia was the most common presenting indication for ECT, followed by psychosis and suicidal ideation. For all patients, Clinical Global Impressions-Improvement scale scores indicated that it was very likely for a subject to experience at least "much improvement" with the estimated probability of receiving a Clinical Global Impressions-Improvement scale score better than 3 of 0.852 (t.s. = 16.3; P < 0.001; 95% confidence interval, 0.711-0.931). All patients with catatonia demonstrated a positive clinical response and experienced a statistically significant reduction in total Bush-Francis Catatonia Rating Scale scores observed (t = 11.9; df = 20; SD = 6.3; P < 0.001; 95% confidence interval, 12.6-17.9). No significant adverse events were reported for any patient in the cohort. However, 14 (38.9%) patients experienced prolonged seizures, all of which were terminated with propofol (mean, 49.7 mg). CONCLUSIONS: This study provides further data supporting the safe and effective use of pediatric ECT in the treatment of various psychiatric conditions. However, more research is needed to determine the risk factors associated with prolonged seizures and the optimal seizure parameters in young people.

Molecular and immunological origins of catatonia.

Catatonia occurs secondary to both primary psychiatric and neuromedical etiologies. Emerging evidence suggests possible linkages between causes of catatonia and neuroinflammation. These include obvious infectious and inflammatory etiologies, common neuromedical illnesses such as delirium, and psychiatric entities such as depression and autism-spectrum disorders. Symptoms of sickness behavior, thought to be a downstream effect of the cytokine response, are common in many of these etiologies and overlap significantly with symptoms of catatonia. Furthermore, there are syndromes that overlap with catatonia that some would consider variants, including neuroleptic malignant syndrome (NMS) and akinetic mutism, which may also have neuroinflammatory underpinnings. Low serum iron, a common finding in NMS and malignant catatonia, may be caused by the acute phase response. Cellular hits involving either pathogen-associated molecular patterns (PAMP) danger signals or the damage-associated molecular patterns (DAMP) danger signals of severe psychosocial stress may set the stage for a common pathway immunoactivation state that could lower the threshold for a catatonic state in susceptible individuals. Immunoactivation leading to dysfunction in the anterior cingulate cortex (ACC)/mid-cingulate cortex (MCC)/medial prefrontal cortex (mPFC)/paralimbic cortico-striato-thalamo-cortical (CSTC) circuit, involved in motivation and movement, may be particularly important in generating the motor and behavioral symptoms of catatonia.

Individual Prediction of Optimal Treatment Allocation Between Electroconvulsive Therapy or Ketamine using the Personalized Advantage Index.

Introduction: Electroconvulsive therapy (ECT) and ketamine are two effective treatments for depression with similar efficacy; however, individual patient outcomes may be improved by models that predict optimal treatment assignment. Here, we adapt the Personalized Advantage Index (PAI) algorithm using machine learning to predict optimal treatment assignment between ECT and ketamine using medical record data from a large, naturalistic patient cohort. We hypothesized that patients who received a treatment predicted to be optimal would have significantly better outcomes following treatment compared to those who received a non-optimal treatment. Methods: Data on 2526 ECT and 235 mixed IV ketamine and esketamine patients from McLean Hospital was aggregated. Depressive symptoms were measured using the Quick Inventory of Depressive Symptomatology (QIDS) before and during acute treatment. Patients were matched between treatments on pretreatment QIDS, age, inpatient status, and psychotic symptoms using a 1:1 ratio yielding a sample of 470 patients (n=235 per treatment). Random forest models were trained and predicted differential patientwise minimum QIDS scores achieved during acute treatment (min-QIDS) scores for ECT and ketamine using pretreatment patient measures. Analysis of Shapley Additive exPlanations (SHAP) values identified predictors of differential outcomes between treatments. Results: Twenty-seven percent of patients with the largest PAI scores who received a treatment predicted optimal had significantly lower min-QIDS scores compared to those who received a non-optimal treatment (mean difference=1.6, t=2.38, q<0.05, Cohen's D=0.36). Analysis of SHAP values identified prescriptive pretreatment measures. Conclusions: Patients assigned to a treatment predicted to be optimal had significantly better treatment outcomes. Our model identified pretreatment patient factors captured in medical records that can provide interpretable and actionable guidelines treatment selection.

Residual symptoms following electroconvulsive therapy: A retrospective cohort study.

BACKGROUND: Residual depressive symptoms following treatment are a burden for patients and are associated with increased risk of relapse. While this phenomenon has been explored following pharmacotherapy, there is little research into residual symptoms following electroconvulsive therapy (ECT). This study quantifies the frequency and type of residual symptoms following ECT treatment. METHODS: This study used retrospective data from patients receiving ECT as part of routine clinical care. Depressive symptomatology was assessed using the Quick Inventory of Depressive Symptomatology - Self-Report 16 item scale (QIDS), which includes 9 symptom domains graded from 0 to 3. We quantified the frequency of mild or greater (QIDS≥1) and moderate or greater (QIDS ≥ 2) residual symptoms following treatment among patients responding to ECT (QIDS decrease ≥50 % from baseline) and non-responders (QIDS decrease <50 %). RESULTS: Among 1799 patients, 1015 (56.4 %) responded to ECT and 784 (43.6 %) did not. Among responders, 99.5 % had at least one residual symptom of mild severity or greater (median = 5, IQR = 3-6) and 83.3 % had at least one residual symptom of moderate severity or greater (median = 1, IQR = 1-2). Among non-responders, 100 % had residual symptoms of mild severity or greater (median = 8, IQR = 7-9), and 99.2 % had a residual symptom of moderate severity or greater (median = 4, IQR = 3-5). The most common residual symptoms among both responders and non-responders were sleep disturbances (93.1 % and 98.7 %, respectively) and sadness (68.9 % and 96.4 %, respectively). LIMITATIONS: Retrospective data from a single freestanding psychiatric hospital. CONCLUSION: Among patients with depression receiving ECT, there were high rates of residual symptoms even among patients responding to treatment.

Changes in self-reported suicidal ideation during treatment with electroconvulsive therapy: A retrospective cohort study.

OBJECTIVE: Suicidal ideation (SI) is common in patients with depressive symptoms, who are the most common recipients of electroconvulsive therapy (ECT). We sought to quantify changes in self-reported SI occurring during treatment with ECT, and to identify factors associated with persistence of SI in patients beginning treatment with SI. METHOD: Retrospective, single-center cohort study of patients receiving ECT and who self-reported symptoms using Quick Inventory of Depressive Symptomatology (QIDS) prior to ECT and after treatment #5 or #10. Changes in QIDS-reported SI over the course of ECT were calculated, and logistic regression models were performed to assess factors associated with reporting SI at the end of treatment. RESULTS: 2554 provided baseline and follow-up SI scores, of whom, 1931 (75.6%) endorsed SI at baseline. There was a reduction in SI with ECT treatment (McNemar's test; df = 1, Χ2 = 803.7; p < 0.001), and in adjusted models 64.0% of individuals with baseline SI reported resolution of SI with ECT treatment, while 3.3% without baseline SI reported SI at the end of treatment. Higher baseline SI severity and outpatient treatment were associated with a higher odds of persistent SI among individuals beginning treatment with SI. CONCLUSION: Electroconvulsive therapy treatment was associated with reductions in self-reported SI. These results support the use of ECT in the treatment of patients with SI, but further research is needed to determine the effects of ECT on suicidal behavior.

Alternative psychopharmacologic treatments for pediatric catatonia: a retrospective analysis.

Introduction: Pediatric catatonia is a highly co-morbid condition with treatment options often limited to electroconvulsive therapy (ECT) or lorazepam. However, lorazepam may not be readily available, and access to ECT is limited by restrictive legislation and stigma. This study aims to provide alternative treatment options for pediatric catatonia. Methods: The study involved a single-site retrospective analysis of a private university hospital in the southern United States. The study included patients under eighteen with catatonia who received psychopharmacologic treatment with an agent other than lorazepam. The patients were evaluated with the Bush-Francis Catatonia Rating Scale (BFCRS), Kanner Catatonia Severity Scale (KCS), and Kanner Catatonia Examination (KCE) at the time of initial evaluation and upon stabilization. A retrospective clinical global impressions-improvement (CGI-I) score was assigned by four authors. Results: 102 pediatric patients diagnosed with catatonia were identified, and 31 met criteria for the study. 20 (65%) were white, 6 (19%) were Black, 4 (13%) were Hispanic, and 1 (3%) were Indian. Most patients (N = 18; 58%) were insured by Medicaid. The mean age at the time of catatonia diagnosis was 13.5 years. All patients were stabilized on either clonazepam or diazepam, with 21 (68%) requiring treatment with an additional medication of either an anti-epileptic, N-methyl-D-aspartate (NMDA) receptor antagonist, and aripiprazole or clozapine. Statistically significant reductions in the BFCRS [t = 11.2, df = 30, std = 6.3, p < 0.001, 95% CI = (7.8, 15.1)], KCS [t = 4.6, df = 38, p < 0.001, 95% CI = (12.0, 31.0)], and KCE [t = 7.8, df = 30, std = 1.8, p < 0.001, 95% CI = (1.9, 3.2)] were observed. For CGI-I the results showed that the estimated probability of observing a score better than no change (>4) is 0.976 [t.s. = 43.2, p < 0.001, 95% CI = (0.931,0.992)], indicating the average subject is expected to experience some improvement. Discussion: In conclusion, all patients responded to these treatments with improvement in their catatonic symptoms. Alternative pharmacologic interventions for catatonia, including benzodiazepines other than lorazepam, valproic acid, NMDA receptor antagonists, and atypical antipsychotics were safe and effective in treating catatonia in this population.

Changes in deep brain stimulation surgeries between 2019 and 2020: A national inpatient sample analysis.

Background: Deep brain stimulation (DBS) surgery is a neurosurgical procedure that implants electrodes into the brain to treat a variety of neurological and psychiatric conditions. The COVID-19 pandemic resulted in significant disruptions in elective surgeries, but the impact on DBS surgeries remains largely unknown. Methods: The National Inpatient Sample (NIS), an all-payors database of inpatient hospitalizations in the US, was queried for DBS implantation procedural codes in 2019 and 2020. Results: There were a total of 7,625 hospitalizations (95% CI: 6,664 to 8,586) for the implantation of a DBS lead in the 2019 NIS, which reduced by 11.9% to 6,715 hospitalizations (95% CI: 5,872 to 7,558) in the 2020 NIS. Procedural numbers declined in March 2020, with a peak 92.7% decline in volume in April of 2020 relative to 2019. Case numbers for July through December 2020 were 96.1% of the 2019 volume. Overall patient demographics and primary discharge diagnoses for hospitalizations involving DBS implantation were similar in the two study years. Conclusions: Surgical volume for DBS implantation reduced by 92.7% in April of 2020 relative to 2019, which is among the highest declines reported for any surgical procedure. While procedural volume increased in the second half of 2020, this did not make up for the reduction in procedures earlier in the year, highlighting the disruption in DBS surgeries in 2020.

Opportunistic salpingectomy during non-gynaecological surgery in the United States: a population-based retrospective study.

The most common type of ovarian cancer likely begins in the fallopian tubes. Surgically removing the fallopian tubes decreases a person's risk of ovarian cancer. 'Opportunistic salpingectomy' refers to the removal of the fallopian tubes during surgery that is done for other reasons. Opportunistic salpingectomy is commonly done during hysterectomy. The types of other surgery performed together with opportunistic salpingectomy in the USA were analysed in the present study. Opportunistic salpingectomy was found to be done at the time of bariatric surgery, bowel surgery, hernia repair, gallbladder surgery, and breast surgery. Offering opportunistic salpingectomy to all women who are scheduled for those types of surgeries could lead to between 3600 and 5800 fewer deaths from ovarian cancer in the USA per year.

Evaluation, Treatment, and Referral of Treatment-Resistant Depression in Primary Care.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Prim Care Companion CNS Disord. 2023;25(4):22f03438. Author affiliations are listed at the end of this article.

Changes in Inpatient Electroconvulsive Therapy Utilization Between 2019 and 2020: A National Inpatient Sample Analysis.

OBJECTIVES: Electroconvulsive therapy (ECT) is an essential procedure for a range of psychiatric conditions. Multiple single-center studies have documented reduction in ECT administration in 2020 because of the coronavirus disease 2019 pandemic, but there have been little nationally representative data from the United States. The aim of this study was to examine the demographics of patients receiving ECT in 2019 and 2020 and to characterize temporal and regional variations in ECT utilization. METHODS: The 2019 and 2020 National Inpatient Sample, an administrative database of inpatient hospitalizations in the United States, was queried for hospitalizations involving the delivery of ECT based on procedural codes. Overall number of ECT procedures was calculated based on the overall number of ECT procedural claims. RESULTS: In the 2019 NIS, 14,230 inpatient hospitalizations (95% confidence interval, 12,936-15,524) involved the use of ECT, with a cumulative 52,450 inpatient ECT procedures administered. In 2020, the number of inpatient hospitalizations with ECT decreased to 12,055 (95% confidence interval, 10,878-13,232), with a 10.0% reduction in overall procedures to 47,180. Whereas January and February ECT hospitalizations were comparable in both years, ECT hospitalizations decreased by more than 25% in March through May 2020 relative to 2019 volume. There was regional variability in the change in ECT utilization between 2019 and 2020. CONCLUSIONS: Electroconvulsive therapy use among general hospital inpatients declined between 2019 and 2020, with regional variability in the magnitude of change. Further study is warranted into the root causes and optimal responses to these changes.

The use of electroconvulsive therapy for children and adolescents in general hospitals: A 2019 kids' inpatient database analysis.

OBJECTIVE: Electroconvulsive therapy (ECT) devices are classified as class II (moderate risk) for the treatment of depressive disorders and catatonia in patients aged 13 and older, but it is unknown how often the treatment is utilized by child and adolescent patients. The aim of this study was to examine the demographics of child and adolescent hospitalizations involving ECT, the medical and psychiatric comorbidities of these hospitalizations, and the overall number of treatments administered per hospitalization. METHOD: The 2019 Kids' Inpatient Database, a national sample of pediatric discharges from 3998 acute care hospitals, was analyzed for hospitalizations involving patients aged 19 and younger receiving ECT based on inpatient procedural codes. RESULTS: 315 (95% confidence interval 275 to 354) discharges among child and adolescent patients, or 0.03% of youth hospitalizations, involved the administration of ECT in the KID in 2019. Hospitalizations in the Northeast, those involving patients residing in ZIP codes in the top income quartile, and those for commercially insured patients had higher odds of ECT administration. Primary discharge diagnoses among ECT recipients were major depressive disorder (143; 46.4%), schizophrenia and other psychotic disorders (71; 23.1%) and bipolar disorder (59; 19.2%). In total 153 (48.6%) of ECT recipients had a coded diagnosis of suicidal ideation. Hospitalizations involved a median of 2 (IQR 1 to 5) ECT treatments before discharge. CONCLUSIONS: ECT is rarely utilized in the inpatient treatment of child and adolescent patients, but is most often administered to patients with mood and psychotic disorders. Commercial insurance and higher income were associated with higher odds of ECT administration, suggesting that access to care may be limited.

Coding for Physical Restraint Status Among Hospitalized Patients: a 2019 National Inpatient Sample Analysis.

BACKGROUND: The reduction of physical restraint utilization in the hospital setting is a key goal of high-quality care, but little is known about the rate of restraint use in general hospitals in the USA. OBJECTIVE: This study reports the rate of physical restraint coding among acute care hospital discharges in the USA and explores associated demographic and diagnostic factors. DESIGN: The National Inpatient Sample, a de-identified all-payors database of acute care hospital discharges in the USA, was queried for patients aged 18 and older with a diagnosis code for physical restraint status in 2019. PARTICIPANTS: Hospitalized patients aged 18 and older. MAIN MEASURES: Demographics, discharge diagnoses, in-hospital mortality, length of stay, total hospital charges. KEY RESULTS: In total, 220,470 (95% CI: 208,114 to 232,826) hospitalizations, or 0.7% of overall hospitalizations, included a discharge code for physical restraint status. There was a 700-fold difference in coding for restraint utilization based on diagnosis, with 7.4% of patients with encephalitis receiving restraint diagnosis codes compared to < 0.01% of patients with uncomplicated diabetes. In an adjusted model, male sex was associated with an odds ratio of 1.4 (95% CI: 1.4 to 1.5) for restraint utilization coding, and Black race was associated with an odds ratio of 1.3 (95% CI: 1.2 to 1.4) relative to white race. CONCLUSIONS: In the general hospital setting, there is variability in physical restraint coding by sex, race, and clinical diagnosis. More research is needed into the appropriate utilization of restraints in the hospital setting and possible inequities in restraint utilization.

Factors associated with early and late response to electroconvulsive therapy.

OBJECTIVE: Electroconvulsive therapy (ECT) is an effective treatment for severe depressive symptoms, yet more research is needed to examine predictors of treatment response, and factors associated with response in patients not initially improving with treatment. This study reports factors associated with time to response (early vs. late) to ECT in a real-world setting. METHODS: This was a retrospective, single-center cohort study of patients endorsing moderate to severe depressive symptoms using the Quick Inventory of Depressive Symptomatology (QIDS; QIDS>10). Response was defined as 50% or greater decrease in QIDS score from baseline. We used logistic regression to predict response at treatment #5 (early response) as well as after treatment #5 (late response) and followed patients through ECT discontinuation or through treatment #20. RESULTS: Of the 1699 patients included in this study, 555 patients (32.7%) responded to ECT treatment at treatment #5 and 397 (23.4%) responded after treatment #5. Among patients who did not respond by treatment #5, those who switched to brief pulse width ECT from ultrabrief pulse ECT had increased odds of response after treatment #5 compared with patients only receiving ultrabrief pulse (aOR = 1.55, 95% CI: 1.16-2.07). Additionally, patients with less improvement in QIDS from baseline to treatment #5 had decreased odds of response after treatment #5 (aOR = 0.97, 95% CI = 0.97-0.98). CONCLUSION: Among depressed patients treated with ECT, response occurred in 56.0% of patients by treatment #20. Patient receiving ultrabrief pulse ECT at baseline and who did not respond by treatment #5 had greater odds of subsequent response if switched to brief pulse ECT than if continued with ultrabrief pulse.