Is electroconvulsive therapy use among young-old and old-old adults comparable? A 10-year population-level analysis of service provision.

OBJECTIVES: Existing research on electroconvulsive therapy (ECT) in older adults has largely examined its efficacy and safety in treating depression, but there are few population-level studies of its use in this patient group. Our objective was to provide a comprehensive 10-year picture of ECT use among adults aged 65 years and older in the State of Victoria, Australia. We focused especially on comparing patterns of ECT use between young-old and old-old individuals, to better inform practicing physicians, policy makers, and researchers about ECT practices in this diverse range of patients. METHODS: We analyzed statewide ECT service provision data from 1998 to 2007 provided by the Office of the Chief Psychiatrist of Victoria. RESULTS: Age-adjustment of crude data revealed that old-old adults had the highest rate of ECT use overall (especially women) as well as the highest utilization rates for depression and public sector treatment. Although the highest rate of exclusively involuntary treatment under the Mental Health Act was also observed among old-old adults, most of the old-old patients were treated on an exclusively voluntary basis. The number of ECT treatments administered to young-old and old-old patients did not differ. CONCLUSIONS: The higher ECT utilization rates we previously reported in older adults as a whole were further accentuated in old-old individuals. Old-old adults may have medical comorbidities and personal care needs that have implications for ECT technique and service delivery. Our findings underscore the need for greater inclusion of old-old patients in future ECT research to increase its clinical applicability.

Are reports of cognitive testing among older electroconvulsive therapy recipients clinically valid?

OBJECTIVES: Electroconvulsive therapy (ECT) administration rises in frequency with age, with older depressed adults often showing clinical features predictive of good response. Recent reviews suggest that older people experience few if any long-term cognitive adverse effects after contemporary ECT, despite their increased vulnerability to these. However, the broader clinical validity of research findings is not assured as most studies of ECT-related cognitive effects do not discuss cognitive test nonparticipants. This study examines whether cognitive test participants and nonparticipants are comparable. METHODS: We recently completed a study of cognition in depressed patients 65 years and older treated with ECT. Only 35% of eligible patients completed neuropsychological testing at 2 time points, the remainder either refusing or unable to consent. To examine whether exclusion of most eligible patients from cognitive testing might have affected the clinical applicability of findings, we compared demographic and clinical characteristics of patients who participated with those who did not based on a subset of patients from our original study. RESULTS: The 2 patient groups differed in several respects. Most notably, nonparticipants were significantly more likely to be involuntary patients; to refuse food and fluids; and to require treatment with a bitemporal or mixed electrode placement. CONCLUSIONS: Our findings suggest cognitive test nonparticipants to be more severely psychiatrically unwell than test participants. As their exclusion might bias results and confound understanding of this important ECT-related topic, special mention of participation rates and comparison of participants and nonparticipants is recommended to establish the clinical relevance of future study findings.

Balance and gait in older electroconvulsive therapy recipients: a pilot study.

BACKGROUND: Electroconvulsive therapy (ECT) is commonly used to treat depression in older adults. Despite its efficacy in this regard, an associated increase in the risk of falls in this population is a downside of treatment. ECT research has focused on the incidence of falls, but its effect on balance and gait - intrinsic factors in instability and falls - has not been studied. Our aim was to examine changes in balance and gait among older adults before and after a single ECT session and explore the effect of patient-related and treatment factors on any changes found. METHODS: Participants were 21 older adults requiring ECT for depression in public psychiatric services. Patients with clinically overt mobility problems (impairing test participation or increasing the risk of falls) were excluded. Balance and gait testing 1 hour pre-ECT and 1, 2 and 3 hours post-ECT included: (1) steady standing test; (2) perturbation of standing balance by self-initiated movements; (3) perturbation of standing balance by an external perturbation; and (4) timed up and go test. RESULTS: No deterioration in test performance was found, using one-way repeated measures analysis of variance. CONCLUSION: Balance and gait did not deteriorate immediately after ECT. Exclusion of participants with clinically overt mobility problems and falls being better attributable to factors unrelated to balance and gait (such as post-ECT confusion) may account for our findings. This research does not repudiate the occurrence of ECT-related falls but calls into question the utility of introducing routine balance and gait assessment among older ECT recipients without pre-existing mobility problems as a means of preventing them.

Has electroconvulsive therapy use remained stable over time? A decade of electroconvulsive therapy service provision in Victoria, Australia.

OBJECTIVE: Despite the long history of electroconvulsive therapy (ECT) as a psychiatric treatment modality in Australia, existing literature regarding ECT use and practices in Australia is limited. In this unique study, we report ECT provision in Victoria to adults aged 25 years and over from 1998 to 2007, based on complete data from all public and private treatment settings within the State; compare our results to previous literature in the field; and offer possible explanations for these findings as a basis for future research. METHOD: Analysis of statutory ECT service provision data collected by the Office of the Chief Psychiatrist of Victoria. RESULTS: ECT use declined overall from 2001 onward, followed by a small increase in use in 2007. Eighty per cent of patients received ECT for depression and 14% for psychosis. Sixty-two per cent of ECT recipients were women. Although patients aged 65 years and over were small in number, age adjustment of data was indicative of a higher utilisation rate in this group. With increasing age, the percentage of ECT recipients treated for depression increased, whereas the percentage treated for psychosis decreased. Sixty per cent of patients were treated in the public sector. Public-private sector ECT use did not differ greatly for depression, but more patients were treated in the public sector for psychosis. The majority of patients with depression received treatment voluntarily, but the converse was true for patients with psychosis. Unilateral electrode placement predominated. CONCLUSIONS: While utilisation rates gradually declined over the decade studied, patients continued receiving ECT in significant numbers, suggesting its role in treating severe mental illness is far from superceded. The present, population-level research cannot explain the causative factors underlying the patterns observed, but raises interesting questions for further investigation. Ongoing collection of statutory ECT data in a manner making it amenable to research applications is recommended.

Specialist mental health consultation for depression in Australian aged care residents with dementia: a cluster randomized trial.

OBJECTIVE: This cluster randomized controlled trial sought to determine whether multidisciplinary specialist mental health consultation was more effective than care as usual in treating the depression of aged care residents with dementia. METHODS: Three hundred and eighty nine aged care residents were screened for dementia and major depression. Forty four were ultimately included in the intervention sample, selected from 20 aged care facilities located in Melbourne, Australia. Facilities were randomly allocated to an intervention condition involving the provision of multidisciplinary specialist consultation regarding the best-practice management of depression in dementia, or to a care as usual condition. Consultations involved individually tailored medical and psychosocial recommendations provided to care staff and general practitioners. All residents participated in a comprehensive pre-intervention diagnostic assessment, including the administration of the Cornell Scale for Depression in Dementia. This assessment was repeated approximately 15 weeks post-intervention by a rater blind to study condition. RESULTS: Multidisciplinary specialist mental health consultation was significantly more effective than care as usual in treating the clinical depression of aged care residents with dementia (p < 0.05, partial η(2) = 0.16). At follow-up, the mean Cornell Scale for Depression in Dementia score for the intervention group was 9.47, compared with 14.23 for the control group. In addition, 77% of the intervention group no longer met criteria for major depression. CONCLUSIONS: The results of this study suggest that the psychosocial and medical management of depressed aged care residents can be improved by increasing access to specialist mental health consultation.

The change in electrical energy delivered to aged patients over a course of moderate dose unilateral electroconvulsive therapy.

BACKGROUND: To prove effective, the electrical energy delivered as part of unilateral electroconvulsive therapy (ECT) must exceed the seizure threshold. Although high dose treatment (six times the threshold) is most effective, it results in more cognitive deficits to which aged patients are especially vulnerable. As a compromise, Australian psychogeriatricians often prescribe moderate dose (three times the threshold) treatment. However, older patients' thresholds sometimes rise steeply as treatment progresses. If energy levels are kept low to make treatment safer, the result might be that patients' recovery is delayed. We report here on changes in prescribed energy over a course of six unilateral treatments. METHODS: A retrospective review of data collected routinely on 42 depressed patients aged ≥ 65 years given moderate dose unilateral ECT in five aged psychiatry services in Victoria, Australia. RESULTS: Prescribed energy rose with time, but only 31% of patients reached high dose levels by their sixth treatment. CONCLUSIONS: We cannot comment on the safety or effectiveness of moderate dose ECT. We focus instead just on changes in prescribed energy levels. These did not rise quickly in most cases, suggesting that moderate dose ECT cannot be dismissed as a treatment option simply because of the rate of change in electrical stimulation.

Neuropsychological testing of culturally and linguistically diverse individuals: the case of Greek-speaking individuals.

PURPOSE OF REVIEW: The aim of this review is to update clinicians and researchers regarding neuropsychological tools that have been normed in Greece, thereby assisting them to improve diagnostic accuracy when undertaking neuropsychological assessment of Greek-speaking individuals. RECENT FINDINGS: A growing number of neuropsychological tests of cognition have been normed in the healthy Greek adult population and the findings reported in the English-language literature. Neuropsychological Greek normative studies have revealed performance differences in Greek speakers. In general, research findings indicate that population-specific norms are required for accurate neuropsychological assessment of the Greek adult population. SUMMARY: Validating neuropsychological tests of cognition in healthy Greek adults improves clinicians' and researchers' ability to accurately assess, diagnose and manage Greek individuals with cognitive disorders. Normative studies in Greek-speaking clinical populations and studies examining performance differences between native Greek speakers and the Greek diaspora are directions for future research.