Community-supported teaching on the topic of transgender identity in undergraduate medical education - a pilot project.

Introduction and objectives: Future physicians are insufficiently prepared for the topic of transgender identity during their studies. Relevant courses during undergraduate medical education are heterogeneous and not widely established within the curricula. At our university, we investigated if students' knowledge of transgender identity could be increased through medical specialist teaching and teaching delivered by representatives of the trans* community (community-supported teaching). Methods: During summer semester 2021 (SS21), the knowledge level on transgender identity of 134 medical students in their fifth clinical semester was evaluated (phase 1). In addition, knowledge gain on gender incongruence through the module "psychiatry" was retrospectively surveyed across two dimensions: 1. diagnostic criteria, 2. treatment/care. During winter semester 2021/22 (WS 21/22), a 90-minute seminar on transgender identity was held either community-supported or by medical specialists (phase 2). Following the psychiatry exam, a re-evaluation was carried out by 115 students (phase 3). Results: The students in SS21 did not feel sufficiently educated in the topic of transgender identity through their studies, but rated the relevance of the topic for their later profession as high. Learning gain improved after the introduction of the seminar in WS21/22 compared to the previous semester (both dimensions p<.001). Community-supported and specialist teaching achieved equivalent results. Conclusion: One 90-minutes seminar led to a significant learning gain regarding the topic of transgender identity. Community-supported teaching is a promising way to impart knowledge in a qualified manner: Medical faculties should use this form of teaching to convey established knowledge to students in future curricula.

Baseline levels of miR-223-3p correlate with the effectiveness of electroconvulsive therapy in patients with major depression.

There is a strong medical need to develop suitable biomarkers to improve the diagnosis and treatment of depression, particularly in predicting response to certain therapeutic approaches such as electroconvulsive therapy (ECT). MicroRNAs are small non-coding RNAs that have the ability to influence the transcriptome as well as proteostasis at the systems level. Here, we investigate the role of circulating microRNAs in depression and response prediction towards ECT. Of the 64 patients with treatment-resistant major depression (MDD) who received ECT treatment, 62.5% showed a response, defined as a reduction of ≥50% in the MADRS total score from baseline. We performed smallRNA sequencing in blood samples that were taken before the first ECT, after the first and the last ECT. The microRNAome was compared between responders and non-responders. Co-expression network analysis identified three significant microRNA modules with reverse correlation between ECT- responders and non-responders, that were amongst other biological processes linked to inflammation. A candidate microRNA, namely miR-223-3p was down-regulated in ECT responders when compared to non-responders at baseline. In line with data suggesting a role of miR-223-3p in inflammatory processes we observed higher expression levels of proinflammatory factors Il-6, Il-1b, Nlrp3 and Tnf-α in ECT responders at baseline when compared to non-responders. ROC analysis of confirmed the diagnostic power of miR-223-3p demarcating ECT-responders from non-responder subjects (AUC = 0.76, p = 0.0031). Our data suggest that miR-223-3p expression and related cytokine levels could serve as predictors of response to ECT in individuals with treatment-resistant depressive disorders.

Effects of Anesthesia Changes During Maintenance ECT: A Longitudinal Comparison of Seizure Quality Under Anesthesia Using Propofol/Esketamine Versus Methohexital.

INTRODUCTION: The effectiveness of ECT relies on the induction of a generalized cerebral seizure. Among others, seizure quality (SQ) is potentially influenced by the anesthetic drug used. Commonly used anesthetics comprise barbiturates, etomidate, propofol, and esketamine, with different characteristics and impacts on seizure parameters. So far, no studies have compared the influence of methohexital vs. a combination of propofol/esketamine on established SQ parameters. METHODS: This retrospective longitudinal study compared eight established SQ parameters (PSI, ASEI, MSC, midictal amplitude, motor and electroencephalography (EEG) seizure duration, concordance, PHR) before and after the change from propofol/esketamine to methohexital in 34 patients under maintenance ECT. Each patient contributed four measurements, two before and two after the anesthesia change. Anesthesia dose, stimulus dose, electrode placement, and concomitant medication remained unchanged throughout the analyzed treatments. RESULTS: Under methohexital (M=88.97 mg), ASEI (p=0.039 to 0.013) and midictal amplitude (p=0.022 to<0.001) were significantly lower, whereas seizure duration (motor and EEG) was significantly longer when compared to propofol/esketamine (M=64.26 mg/51.18 mg; p=0.012 to<0.001). PSI, MSC, seizure concordance, and PHR were not affected by the anesthetic used. DISCUSSION: Although to what extent these parameters correlate with the therapeutic effectiveness remains ambiguous, a decision for or against a particular anesthetic could be considered if a specific SQ parameter needs optimization. However, no general superiority for one specific substance or combination was found in this study. In the next step, anesthetic effects on treatment response and tolerability should be focused on.

[Health service aspects of electroconvulsive therapy: analysis of external referrals to a university medical center]. / Versorgungsaspekte der Elektrokonvulsionstherapie: Analyse der externen Zuweisungen an ein universitäres Zentrum.

BACKGROUND: The application of ECT in Germany varies widely depending on regional availability. This shortfall in ECT supply is partly compensated via referrals to hospitals with ECT services, yet restricted by limited resources in these clinics. OBJECTIVE: External referrals for ECT were investigated at the University Medical Center Göttingen. We analyzed the referring institutions, patient characteristics, pharmacotherapy according to current guidelines before indications for ECT, and clinical outcome in cases of treatment with ECT. MATERIAL AND METHODS: All external referrals were systematically recorded and retrospectively evaluated for the time span of 1 year. Besides descriptive presentation of the data, pharmacological pretreatment was compared with the current guideline recommendations. We used overall clinical impression (CGI-I) to determine the treatment response post-ECT. RESULTS: External referrals were made for N = 52 patients, 82.7% of whom were from the inpatient setting and from a distance of up to 300 km. The most common diagnoses were unipolar depression (57.7%), followed by schizophrenia spectrum (36.5%). Prior to referral, at least one guideline-based pretreatment was given in the majority of cases. ECT was performed in 18 patients in our hospital, of whom 72.7% showed a good to very good response. CONCLUSION: Both numbers and radius of external referrals indicate a high unmet need for ECT and thus limited access to this evidence-based and guideline-recommended therapy. As treatment close to home should be the goal, more hospitals are needed to establish (or expand) ECT services; however, even with considerable delays which are often associated with external referrals, the response rate is good across all diagnoses.

Electroconvulsive Therapy in Children and Adolescents in Germany-A Case Series From 3 University Hospitals.

OBJECTIVE: Electroconvulsive therapy (ECT) is a well-established, safe, and efficacious treatment for severe psychiatric disorders. In children and adolescents, it is used much less frequently than in adults, likely because of a lack of knowledge. METHODS: We retrospectively analyzed all patients aged 12 to 17 years who completed a course of ECT at 3 psychiatric university hospitals in Germany between 2010 and 2020. Clinical Global Impression Severity (CGI-S) scores were assessed based on electronic medical records. Changes in CGI-S scores were assessed using a paired samples t test. Predictors for response and remission were assessed using binomial logistic regression. RESULTS: We included 32 patients. The CGI-S scores improved significantly from before to after ECT treatment (6.9 vs 3.9, t = 10.0, P < 0.01). A total of 40.6% of patients responded (CGI ≤ 3) and 21.9% remitted (CGI ≤ 2). The number of ineffective medication trials in the 6 months before ECT treatment was significantly associated with response (odds ratio, 0.54; P = 0.028) and remission (odds ratio, 0.31; P = 0.048). Five patients reported subjective cognitive adverse effects, 2 patients exhibited a prolonged seizure, 1 patient reported headaches, and 1 patient experienced a mild allergic reaction after anesthesia with etomidate. A total of 65.6% of patients experienced no adverse effects at all. CONCLUSIONS: This retrospective analysis found ECT to be effective and safe in children and adolescents irrespective of their main diagnosis. The reported data point to the importance of an early use of ECT for severe psychiatric diseases in child and adolescent psychiatry.

Effectiveness of maintenance electroconvulsive therapy-Evidence from modifications due to the COVID-19 pandemic.

OBJECTIVE: Continuation and maintenance ECT (c-/m-ECT) are effective in the prevention of relapse and recurrence of both affective and psychotic disorders. However, data are scarce concerning the trajectories of severe mental disorders after the end of c-/m-ECT. This prospective study investigates the clinical outcome of patients with versus without modifications of their c-/m-ECT schedules. METHODS: In the context of the COVID-19 pandemic, ECT capacities were restricted at many clinics in early 2020. All patients receiving c-/m-ECT in March and April 2020 at our department (n = 53, unipolar depression, bipolar disorder, schizophrenia) were followed up for six months to investigate the impact of treatment modifications imposed by the pandemic. Based on individual decisions, c-/m-ECT was either (a) continued without modification, (b) continued with reduced frequency, or (c) discontinued. RESULTS: Both reduced frequency and discontinuation of c-/m-ECT were associated with significant clinical deterioration as measured by CGI-I (Clinical Global Impression Scale - Global Improvement) during the six-month follow-up when compared to the subgroup of patients without any treatment modification (p = 0.005, p = 0.011). Furthermore, patients with discontinued or reduced c-/m-ECT showed significantly higher rates of rehospitalizations (p = 0.028) and new acute courses of ECT (p = 0.018). CONCLUSION: Despite the limitations of a heterogeneous and relatively small sample, our study strongly corroborates the effectiveness of c-/m-ECT in a real-world population. Especially, patients with shorter time since index ECT seem to be at high risk for severe clinical deterioration in the case of treatment discontinuation or reduction.

[Use of electroconvulsive therapy in adolescents - A retrospective survey on 12- to 17-year-old patients at three university hospitals in Germany]. / Elektrokonvulsionstherapie im Kindes- und Jugendalter.

Use of electroconvulsive therapy in adolescents - A retrospective survey on 12- to 17-year-old patients at three university hospitals in Germany Abstract. Abstract. Background: Electroconvulsive therapy (ECT) is a highly effective and well-researched therapy in adult psychiatry and has been successfully used especially as a treatment for severe depressive, catatonic, and psychotic disorders. Although severe disease progressions also occur in child and adolescent psychiatry, ECT is used much less frequently there. This may be because hardly any data have been collected on the use, effectiveness, and tolerability of ECT in child and adolescent psychiatric patients. This article outlines the application, effectiveness, and tolerability of ECT when applied to young adolescents in Germany. Methods: A retrospective survey on ECT in 29 patients under 18 years of age was conducted at three German university centers. All documented cases were recorded and evaluated for effectiveness and tolerability. In addition, a comprehensive PubMed-based database search was carried out. Results and conclusions: Internationally, there are no meta-analyses or randomized controlled studies and hardly any published cases on electroconvulsive therapy in German child and adolescent psychiatry. Our data on ECT show high efficacy in previously treatment-resistant and severely ill patients. Side effects occurred rarely. There was no evidence of differences between adults and adolescents in indication (depression, catatonia, schizophrenia), effectiveness, tolerability, and negative predictors of response to ECT. The results also suggest that the use of ECT in adolescents should be considered earlier in the treatment course.

Overlooking the obvious? Influence of electrolyte concentrations on seizure quality parameters in electroconvulsive therapy.

Clinical response to electroconvulsive therapy (ECT) depends on eliciting a generalized seizure. Though there are multiple ictal and other parameters to assess seizure quality, factors that influence these parameters have only been identified to a limited extend in antecedent studies (e.g., stimulus dosage, age). In the context of ECT, electrolyte concentrations have hardly been investigated so far-although hyponatremia is one well-known clinical factor to increase the risk of spontaneous seizures. In 31 patients with unipolar or bipolar depressive disorder, blood concentrations of sodium (Na), potassium (K), and calcium (Ca) were measured immediately prior to repeated sessions of maintenance ECT. Generalized linear mixed models were used to analyze the influence of Na, K, and Ca on seven seizure quality parameters: postictal suppression index (PSI), maximum sustained coherence (MSC), midictal amplitude, average seizure energy index, seizure duration (EEG/motor), and peak heart rate. Results show a statistically significant relationship between the serum sodium level and MSC: in the model, a reduction of 1 mmol/l led to an increase in interhemispheric coherence of 0.678%. The further markers remained unaffected by changes in electrolyte concentrations. This finding provides first evidence that a lower blood concentration of sodium could enhance the quality of ECT-induced seizures in terms of higher interhemispheric coherence.

Serum neurofilament light chain (NFL) remains unchanged during electroconvulsive therapy.

Objectives: Although there is consistent evidence that electroconvulsive therapy (ECT) is safe and well tolerated by the majority of patients, some authors still accuse ECT to inevitably cause brain damage and permanent memory loss, assertions that may increase patients' worries about a useful treatment. Recently, the measurement of neurofilament light chain (NFL) in peripheral blood was technically implemented, permitting longitudinal analysis of this biomarker for axonal damage. NFL is part of the axonal cytoskeleton and is released into the CSF and peripheral blood in the context of neuronal damage.Methods: In our study, blood from 15 patients with major depressive disorder receiving ECT was collected before the first ECT as well as 24 h and seven days after the last ECT, respectively. NFL concentrations were analysed using the ultrasensitive single molecule array (Simoa) technology.Results: NFL concentrations did not differ between patients and healthy controls, and there was no significant change in NFL levels in the course of ECT. On the contrary, we even found a slight decrease in absolute NFL concentrations.Conclusions: Our study confirms the safety of ECT by using a most sensitive method for the detection of NFL in peripheral blood as a biomarker of neuronal damage.

Electroconvulsive Therapy in Incapable Patients Refusing Treatment: Prevalence, Effectiveness, and Associated Factors.

OBJECTIVES: Severe psychiatric disorders may be accompanied by life-threatening conditions, lack of insight, and treatment refusal. Involuntary treatment may be indicated in patients who lack capacity to consent and refuse treatment. In this context, there is a lack of systematic data regarding the use of electroconvulsive therapy (ECT) in Germany. METHODS: A questionnaire with 25 items comprising quantitative and qualitative data was sent to all psychiatric hospitals in Germany that perform ECT. Cases of ECT treatment in incapable patients refusing therapy were identified retrospectively in a 12-month period. RESULTS: Fifty-three hospitals completed the questionnaire, and 15 cases of ECT in incapable and refusing patients were reported. A marked clinical response was observed in 14 patients. Capacity to consent was restored in 11 patients. In contrast to this particularly good effectiveness, psychiatrists' attitudes revealed a widespread lack of experience as well as reservations and uncertainties regarding the use of ECT against the patient's wishes. CONCLUSIONS: In line with other recent publications, our data suggest a very good benefit-to-risk ratio for ECT in incapable patients refusing the treatment, while at the same time the provision of ECT in such patients is rare in Germany. In light of the scarcity of treatment alternatives and the possible consequences of a refusal to perform ECT in life-threatening conditions, a general rejection of involuntary ECT does not seem ethically appropriate.

Factors Influencing Staff's Attitude Toward Electroconvulsive Therapy: A Comparison of New Versus Experienced Electroconvulsive Therapy Clinics.

OBJECTIVES: Despite being a highly effective treatment, electroconvulsive therapy (ECT) is still stigmatized even among professionals. The aim of this study was to identify factors associated with a positive attitude toward ECT among health care workers. METHODS: We investigated staff's attitude and their self-assessment of knowledge while introducing ECT in 3 German psychiatric clinics. Furthermore, we compared this data to that of a clinic where ECT has been applied with a long tradition. An anonymous questionnaire was answered by n = 182 employees in the ECT-introducing clinics (novices) and n = 68 employees in the clinic with a long history of ECT (experts). RESULTS: Irrespective of the clinical history, the majority of participants approved the application of ECT in their clinic. Factors associated with a positive attitude were (a) profession (physicians presented a more positive mindset about ECT than nursing staff), (b) subjective feeling of being adequately informed, and (c) having had contact to patients undergoing ECT. Interestingly, the general attitude toward ECT did not differ between subjects who reported to have seen an ECT and those who had not. CONCLUSIONS: When introducing ECT as a new treatment into a clinic, formal information should be adapted to the needs of each profession with a special emphasis on nurses. To further increase acceptance, contact to ECT-experienced patients (professionals taught by patients) might result in a more positive attitude toward ECT than participation in an ECT treatment itself.

Electroconvulsive therapy induced gray matter increase is not necessarily correlated with clinical data in depressed patients.

BACKGROUND: Electroconvulsive therapy (ECT) and depression have been associated with brain volume changes, especially in the hippocampus and the amygdala. METHODS: In this retrospective study we collected data from individual pre-post ECT whole brain magnetic resonance imaging scans of depressed patients from six German university hospitals. Gray matter volume (GMV) changes were quantified via voxel-based morphometry in a total sample of 92 patients with major depressive episodes (MDE). Additionally, 43 healthy controls were scanned twice within a similar time interval. RESULTS: Most prominently longitudinal GMV increases occurred in temporal lobe regions. Within specific region of interests we detected significant increases of GMV in the hippocampus and the amygdala. These results were more pronounced in the right hemisphere. Decreases in GMV were not observed. GMV changes did not correlate with psychopathology, age, gender or number of ECT sessions. We ruled out white matter reductions as a possible indirect cause of the detected GMV increase. CONCLUSION: The present findings support the notion of hippocampus and amygdala modulation following an acute ECT series in patients with MDE. These results corroborate the hypothesis that ECT enables primarily unspecific and regionally dependent neuroplasticity effects to the brain.

Electroconvulsive therapy against the patients' will: A case series.

OBJECTIVES: Electroconvulsive therapy (ECT) is the most effective therapy for severe depressive and psychotic disorders. As patients may be subject to legal incapacity and lack of insight, treatment may be administered against the patient's will. There is only limited evidence on the use of ECT against the patient's non-autonomous will. METHODS: We report a series of eight patients who received ECT against their will in two German university medical hospitals between 2014 and 2016. The effectiveness, tolerability and patients' perspective are described. RESULTS: Seven of eight patients were much or very much improved according to the Clinical Global Impression Scale. Capacity to consent was restored in seven patients. Transient side effects occurred in four patients. Seven patients agreed to receive further ECT in the treatment course. CONCLUSIONS: This case series suggests that ECT may (and sometimes should) be administered to severely ill, non-consenting patients against their will with good effectiveness. Potential and mostly moderate and transient side effects have to be weighed up against the potentially life-saving character of ECT in patients with, e.g., suicidality and food refusal. Most importantly, the patients' retrospective appraisal also justifies the administration of ECT in situations of severe mental illness and legal incapacity.

Influence of depressed patients' expectations prior to electroconvulsive therapy on its effectiveness and tolerability (Exp-ECT): a prospective study.

Electroconvulsive therapy (ECT) is the most effective therapy for severe depressive disorders. Though there are known clinical predictors of response (e.g., higher age, presence of psychotic symptoms), there is a lack of knowledge concerning the impact of patients' expectations on treatment outcome and tolerability in terms of possible placebo/nocebo effects. In 31 patients with unipolar or bipolar depressive disorder, we used a questionnaire to investigate the patients' expectations of ECT effectiveness and tolerability prior to and in the course of the treatment. Additionally, the questionnaire was used after the ECT course for a final assessment. Depressive symptoms and putative side-effects were measured at each time point. General linear models were used to analyze the course of depressive symptoms and patients' expectation of ECT effectiveness and tolerability. ECT significantly reduced depressive symptoms with large effect sizes. Patients' rating of ECT effectiveness decreased in parallel: While responders' rating of ECT effectiveness remained stable on a high level, non-responders' rating decreased significantly. Group difference was significant after, but not prior to and during the treatment. Regarding tolerability, there was a (temporary) significant increase in the severity of self-rated symptoms such as headache and memory impairment. In contrast, patients' expectation and assessment of ECT tolerability remained unchanged, and their expectations prior to ECT had no impact on the occurrence of side-effects. These findings contradict the presence of relevant placebo/nocebo effects in the context of ECT when investigating a population of mostly chronic or treatment resistant patients with moderate to severe depressive disorder.

Sex attracts - neural correlates of sexual preference under cognitive demand.

Neurofunctional correlates of sexual arousal are of interest in basic research as well as in clinical science. In forensic psychiatry, it is important to use designs which are potentially robust against susceptibility to manipulation or deception. We tested a new design to measure neurofunctional correlates of sexual preference. Twenty-two healthy heterosexual men had to solve a mental rotation task while sexually preferred or non-preferred distractors were presented simultaneously. With this challenging active task, subjects' possibility to manipulate their response to the sexual stimuli should be lower than in easier tasks and in passive designs. Participants needed more time to solve the mental rotation task when distractors of women and girls were presented compared to distractors of men and boys. FMRI-results showed a network of three brain regions which specifically responded to sexually preferred distractors. Female and adult distractors evoked stronger responses than male and child distractors in regions comprising parahippocampal/fusiform gyrus and amygdala/basal ganglia/thalamus, respectively. Women distractors elicited stronger responses in the inferior parietal lobe compared to all other distractors. Specifically, sexually preferred distractors elicited a weaker downregulation than other distractors. We suppose a different emotion regulation with respect to the sexual relevance of the distractors. To our knowledge, this study is the first to show neurofunctional correlates of sexual preference under cognitive demand. Further studies should examine whether this design is more robust against susceptibility to manipulation than others, in order to be applied as a measurement of sexual preference in forensic patients.