Objectives: Pre-ECT anxiety symptoms are common among patients undergoing Electroconvulsive Therapy (ECT). In this retrospective observational cohort study, we aim to explore the association between pre-ECT anxiety symptoms and ECT treatment outcomes in patients with schizophrenia. Methods: We conducted a retrospective analysis of 979 patients with schizophrenia or schizoaffective disorder who received ECT at a tertiary public psychiatric hospital in Singapore. Patients were categorized into two groups based on the mean value of pre-ECT Brief Psychiatric Rating Scale (BPRS) anxiety subdomain score: with anxiety (>6) and without anxiety (≤6). Changes in clinical outcomes were measured using BPRS-psychotic, BPRS-anxiety, BPRS-negative and BPRS-manic subscale, Global Assessment of Functioning, Clinical Global Impression-improvement (CGI-I), EuroQoL-5 Dimension Visual Analogue Scale (EQ-5D-VAS) and Montreal Cognitive Assessment (MoCA) scale. Associations between the pre-ECT anxiety scores and patient sociodemographic, psychiatric symptom subscales, and functional assessments were analyzed. Results: Younger age, a history of ECT, and concurrent antidepressant use were significantly associated with pre-ECT anxiety symptoms. Higher pre-ECT anxiety scores were positively correlated with psychotic, negative, and manic symptom severity, and were negatively correlated with general functioning and subjective quality of life (EQ-5D-VAS) ( P <0.001). Pre-ECT anxiety was significantly negatively associated with ECT treatment efficacy measured using CGI-I (adjusted β=−0.11, P =0.03; η²=0.01). Conclusion: Our preliminary findings highlight the importance of assessing anxiety symptoms before ECT. Future prospective studies using validated anxiety-specific instruments are needed to further examine and confirm the association between pre-ECT anxiety symptoms and ECT treatment outcomes.
OBJECTIVES:Pre-ECT anxiety symptoms are common among patients undergoing Electroconvulsive Therapy (ECT). In this retrospective observational cohort study, we aim to explore the association between pre-ECT anxiety symptoms and ECT treatment outcomes in patients with schizophrenia. METHODS:We conducted a retrospective analysis of 979 patients with schizophrenia or schizoaffective disorder who received ECT at a tertiary public psychiatric hospital in Singapore. Patients were categorized into two groups based on the mean value of pre-ECT Brief Psychiatric Rating Scale (BPRS) anxiety subdomain score: with anxiety (>6) and without anxiety (≤6). Changes in clinical outcomes were measured using BPRS-psychotic, BPRS-anxiety, BPRS-negative and BPRS-manic subscale, Global Assessment of Functioning, Clinical Global Impression-improvement (CGI-I), EuroQoL-5 Dimension Visual Analogue Scale (EQ-5D-VAS) and Montreal Cognitive Assessment (MoCA) scale. Associations between the pre-ECT anxiety scores and patient sociodemographic, psychiatric symptom subscales, and functional assessments were analyzed. RESULTS:Younger age, a history of ECT, and concurrent antidepressant use were significantly associated with pre-ECT anxiety symptoms. Higher pre-ECT anxiety scores were positively correlated with psychotic, negative, and manic symptom severity, and were negatively correlated with general functioning and subjective quality of life (EQ-5D-VAS) (P<0.001). Pre-ECT anxiety was significantly negatively associated with ECT treatment efficacy measured using CGI-I (adjusted β=-0.11, P=0.03; η²=0.01). CONCLUSION:Our preliminary findings highlight the importance of assessing anxiety symptoms before ECT. Future prospective studies using validated anxiety-specific instruments are needed to further examine and confirm the association between pre-ECT anxiety symptoms and ECT treatment outcomes.
Electroconvulsive therapy (ECT) performed with rocuronium-sugammadex requires both agents to be prepared before each session, creating a persistent syringe-swap risk that compounds with repetition. A 48-year-old woman scheduled for her sixth ECT session received sugammadex 200 mg instead of rocuronium due to syringe misidentification driven by task automaticity accumulated over 5 uneventful preceding sessions. Because the entire sugammadex dose remained unbound in plasma (a state we term "zero-complexation"), subsequently administered rocuronium 100 mg (1.41 mg/kg) failed to achieve adequate neuromuscular blockade. This scenario is pharmacokinetically distinct from the well-described post-reversal re-dosing situation: 200 mg of free sugammadex sequesters ~56 mg of rocuronium, leaving an insufficient effective dose regardless of the total amount administered. The session was postponed and completed the following day uneventfully with standard-dose rocuronium. We present a management algorithm and a safety checklist designed for the repeated-session context of ECT. This case demonstrates that anesthetic teams using rocuronium-sugammadex for ECT must recognize the cumulative automaticity risk inherent in serial sessions and implement structural safeguards accordingly.
Klazomania is a rare phenomenon characterized by compulsive, uncontrollable shouting or yelling without an emotional trigger or reason. It has been reported to be associated with various psychiatric and neurological conditions. No specific treatment has been recommended as the etiology is not known. Trials of antipsychotics, antidepressants, and antiepileptic drugs have been used. Hereby, we report a case of Klazomania in a patient with Obsessive Compulsive Disorder who initially responded to Electroconvulsive Therapy but later on became refractory to it.
Klazomania is a rare phenomenon characterized by compulsive, uncontrollable shouting or yelling without an emotional trigger or reason. It has been reported to be associated with various psychiatric and neurological conditions. No specific treatment has been recommended as the etiology is not known. Trials of antipsychotics, antidepressants, and antiepileptic drugs have been used. Hereby, we report a case of Klazomania in a patient with Obsessive Compulsive Disorder who initially responded to Electroconvulsive Therapy but later on became refractory to it.
Electroconvulsive therapy (ECT) is an effective treatment for severe and treatment-resistant bipolar depression, yet intracranial vascular malformations such as cerebral cavernous malformations raise safety concerns due to transient ECT-induced increases in blood pressure and intracranial pressure, potentially elevating the risk of hemorrhage. We report a case of a woman in her mid-60s with treatment-resistant bipolar depression and severe symptom burden (MADRS 45; HAMD-17 35; HAMD-21 39) in whom brain MRI incidentally revealed a 6×4 mm cavernous hemangioma in the left precentral gyrus without signs of prior hemorrhage. Following interdisciplinary consultation with neurosurgery and anesthesiology, an index course of ECT was initiated with careful hemodynamic monitoring and pharmacological blood pressure control. The patient received 16 sessions; initial bifrontal stimulation yielded insufficient seizure quality despite maximal stimulus intensity, prompting a switch to right unilateral electrode placement, which produced adequate seizures. Hypertensive peaks up to 210/150 mmHg were successfully managed with metoprolol and intravenous urapidil. Apart from transient anisocoria after the first session with unremarkable cranial CT findings, no neurological complications occurred. Depressive symptoms markedly improved by the end of treatment (MADRS 12; HAMD-17 15; HAMD-21 17). This case suggests that ECT can be performed safely and effectively in patients with cerebral cavernous hemangioma when multidisciplinary assessment and targeted hemodynamic management are implemented, and that the combination of metoprolol and urapidil may represent a useful strategy to mitigate blood pressure surges during ECT.
Objectives: To examine the acute and longitudinal effects of repetitive transcranial magnetic stimulation (rTMS) on—autonomic nervous system measures (ANS)—heart rate variability (HRV) and pupillary light reflex (PLR)—in adults with major depressive disorder (MDD). This pilot study explored the feasibility of measurement and associations with clinical outcomes. Methods: Thirteen adults undergoing rTMS for MDD participated in a single-blind, randomized, sham-controlled initial session, followed by 30 open-label treatments. HRV indices [root mean square of successive differences (RMSSD), high-frequency power in normalized units (HFnu)] were recorded at baseline, during stimulation, and biweekly; PLR indices were assessed pre- and post-treatment at rTMS session #1 and at endpoint. Depression severity was measured with the Hamilton Rating Scale for Depression (HRSD). Mixed-effects linear models evaluated changes over time; correlations examined associations between ANS measures and symptom improvement. Results: HRSD scores improved significantly across treatment ( P <0.01), with 4 remitters, 4 responders, and 5 nonresponders. No significant changes were observed in HRV or PLR for the entire sample over the treatment course. However, PLR maximum constriction velocity (MCV) decreased in the active condition versus sham at rTMS session #1 ( P <0.05). There were no significant correlations between changes in HRSD scores and changes in either HRV or PLR variables. Conclusions: Compared with sham stimulation, rTMS induced hyperacute parasympathetic effects on the ANS, as measured by PLR MCV, but this effect was short-lived. ANS measures showed no overall group change over the course of rTMS and no relationship to improvement in depression symptoms.
Objectives: To compare seizure parameters and treatment burden between methohexital and propofol during routine electroconvulsive therapy (ECT), focusing on seizure duration, treatment efficiency, and missed seizures. Methods: This retrospective chart review examined differences in seizure outcomes between 2 commonly used agents, methohexital and propofol, at the Parkwood Institute from October 2017 to October 2019. Results: A total of 132 adult patients were included: 47 received methohexital (mean age 60.9±15.4; 44.7% male) and 85 received propofol (mean age 55.1±17.1; 35.3% male). No significant demographic differences were observed. Methohexital was associated with longer motor (35.6±19.7 vs. 23.4±11.7 s; P <0.001) and EEG (50.8±28 vs. 36.8±19.2 s; P =0.003) seizure durations. It was also directly associated with a higher number of total ECT treatments (13±6.5 vs. 11±5.3; β=0.29, P <0.001), though the raw difference was only marginally significant ( P =0.08). Missed seizures were slightly fewer with methohexital (1.9±2.9 vs. 2.4±2.1; P =0.251). Multilevel structural equation modelling revealed a statistically significant indirect pathway through which methohexital influenced treatment continuity (Estimate = –0.743, P =0.044, standardized β=–0.061), mediated through motor seizure slope and missed seizures. Conclusions: While methohexital may initially enhance seizure quality, its decline in efficacy over time may compromise treatment efficiency. These findings suggest methohexital’s initial seizure advantages may be offset by declining seizure duration across treatments and its downstream association with missed seizures. These findings may inform more efficient ECT anesthetic choices.
Introduction: Electroconvulsive therapy (ECT) is a scientifically recognized and highly effective treatment method for treatment-resistant depressive disorders. ECT-induced cognitive side effects are of particular interest, as neuropsychological deficits considerably contribute to long-term functional outcome. Methods: Fifty-three patients with a severe treatment-resistant unipolar depression participated in on average 11.7 ECT sessions (SD=2.1). Immediately before and after ECT, as well as on average 41 days (SD=7.3) after treatment, a detailed neuropsychological examination with a focus on attention, memory and executive function was performed, and clinical data were collected. Results: Both self-ratings and external ratings indicate a significant response of affective symptoms to ECT-treatment (t1), which largely persisted at the follow-up examination (t2). After ECT (t1), especially in language-semantics and verbal episodic memory, performance worsening was found, but these remitted at t2. Regression analysis revealed a predictive relationship between cognitive performance before ECT (t0) and the extent of cognitive changes shortly after ECT (t1). That is, the higher the cognitive performance before ECT, the more pronounced the cognitive side effects were likely to be. A clear discrepancy could be shown with respect to objective cognitive performance and subjective cognitive complaints, as well as for symptom severity and cognitive dysfunction. Conclusion: Our results confirm findings of previous studies, indicating that cognitive decline shortly after ECT in treatment-resistant patients with severe depression is generally temporary and tends to return to baseline or improve over time. Data also show that the validity of cognitive functioning based on self-ratings shortly after ECT-treatment must be queried.
Low-field magnetic stimulation (LFMS) has shown promising results for treating depression in preclinical and clinical studies. No previous meta-analysis has investigated its effects on depression. The aim of this systematic review and meta-analysis is to identify, evaluate, and summarize the current evidence for the efficacy and tolerability of LFMS in patients with depressive disorder. PubMed, Embase, Scopus, and Google Scholar databases were systematically searched to identify eligible studies published until February 15, 2025. Review protocol was prospectively registered with PROSPERO (CRD420250650519). Meta-analyses using a random-effects model was conducted to calculate pooled estimates. Standardized mean difference (SMD) and odds ratio (OR) were calculated for continuous and categorical outcomes, respectively. Nine randomized controlled trials (RCTs) comprising 571 patients were analysed. Five RCTs (55.5%) had 'some concerns', and 2 (22.2%) had a 'high risk' of bias. A moderate treatment effect size (SMD=-0.61; 95% CI: –0.91 to –0.30; P <0.001) favouring LFMS for the treatment of depression compared with sham stimulation was obtained. LFMS was well-tolerated with no significant difference in the frequency of adverse events reported between LFMS and sham groups, except for a significantly higher risk of myalgia associated with LFMS (OR=2.69; 95% CI: 1.14-6.31, P =0.02). Certainty of evidence on GRADE was 'low' for the primary outcome. LFMS may be a safe and effective neuromodulation technique for adjunctive treatment of depression. There is a need to conduct more robust RCTs with larger sample sizes, longer follow-up durations, and standardized LFMS stimulation parameters to better characterize its safety and efficacy.
Introduction: Postictal EEG suppression is considered a key indicator of seizure quality during electroconvulsive therapy (ECT); however, its biological correlates remain incompletely understood. Emerging evidence suggests that systemic inflammatory activity may influence cortical recovery following induced seizures. Whether this neuroimmune interaction differs across psychiatric diagnoses has not been systematically examined. Methods: This retrospective cross-sectional study analyzed EEG parameters recorded during ECT together with peripheral inflammatory markers in 60 patients undergoing ECT. The primary focus was schizoaffective disorder, with bipolar disorder and other diagnoses examined for comparison. EEG indices included tonic and clonic phase durations and postictal suppression. Inflammatory measures comprised C-reactive protein (CRP), neutrophil counts, hemoglobin levels, and composite indices such as the Inflammatory Burden Index (IBI). Associations were evaluated using Spearman correlation analyses with correction for multiple comparisons. Results: In the schizoaffective disorder subgroup, postictal duration showed strong and biologically coherent associations with inflammatory markers, including a significant inverse correlation with neutrophil count that remained robust after false discovery rate correction. Additional associations with hemoglobin levels and IBI were observed. In contrast, bipolar disorder demonstrated only a limited association between postictal duration and CRP, while other EEG-inflammatory relationships were weak or nonsignificant. Discussion: Postictal EEG suppression appears to reflect diagnosis-specific neuroimmune modulation during ECT, with schizoaffective disorder showing particularly pronounced coupling between cortical recovery and systemic inflammatory activity. Postictal EEG features may therefore represent biologically meaningful markers beyond conventional measures of seizure adequacy and contribute to a more mechanistic understanding of ECT response.
Low-intensity transcranial focused ultrasound (tFUS) is a novel noninvasive neuromodulation technique capable of reaching deep brain structures with high spatial precision. The anterior thalamus, a key relay in pain processing, is a promising target for modulating central pain networks. In this context, this study aims to assess the safety, feasibility, and preliminary effects of anterior thalamic low-intensity tFUS in patients with chronic Central Neuropathic Pain (CNP). In this prospective, open-label, single-arm pilot study, 5 adults with refractory central neuropathic pain underwent neuronavigated low-intensity transcranial focused ultrasound targeting the anterior thalamus contralateral to the pain-affected region. Each session consisted of two 10-minute stimulation blocks separated by 20 minutes. Pain intensity was assessed using the visual analog scale at baseline, immediately poststimulation, and also after 4 hours, 24 hours and 10 days after the intervention. Secondary outcomes included the Brief Pain Inventory, McGill Pain Questionnaire, Douleur Neuropatique 4, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Patient Global Impression of Change and Clinical Global Impression of Change scale. The procedure demonstrated feasible with no serious adverse events. One participant experienced mild transient neck discomfort. No statistically significant improvements were observed in pain intensity or secondary outcomes at any time point compared with baseline. Overall, anterior thalamic low-intensity tFUS presented safe and feasible for patients with CNP but did not yield significant short-term analgesic effects. These findings support further controlled clinical trials with larger samples, optimized stimulation parameters and repeated sessions to better evaluate the therapeutic potential of low-intensity tFUS for chronic CNP.
Background: Postictal agitation (PIA) is a clinically significant complication of electroconvulsive therapy (ECT), reported in approximately 7% to 12% of treatments and associated with safety and workflow concerns. Dexmedetomidine (DEX), a selective α2-adrenergic agonist, may help mitigate PIA while minimizing respiratory suppression. Methods: We retrospectively reviewed 137 ECT sessions in 7 high-risk patients with documented prior PIA requiring rescue anesthetics. DEX was administered using an infusion-rate–based loading protocol of 6 µg/kg/h for 10 minutes, followed by individualized maintenance dosing at 0.2 to 0.7 µg/kg/h until 15 minutes after seizure termination. Posttreatment agitation and sedation were quantified using the Richmond Agitation–Sedation Scale (RASS). Results: RASS scores were within the prespecified target range (−1 to +1) at 15 minutes in 88/137 sessions (64%). Rescue anesthetics were administered for agitation in 18/137 sessions (13%), and extended observation beyond the routine 30 minutes was required in 31/137 sessions (23%). No respiratory depression occurred. Conclusions: In this high-risk cohort, DEX prophylaxis was generally safe and clinically useful for improving postictal behavioral stability, although marked interindividual and intraindividual variability in dose requirements highlights the need for individualized titration and careful monitoring.
Background: Estimating the resting motor threshold (RMT) is crucial for both investigative and therapeutic transcranial magnetic stimulation. However, no gold standard exists, as each method involves trade-offs between accuracy, time, and ease of use. This study compared RMT estimates and trial requirements across 4 EMG-based methods—Rossini-Rothwell (RR), maximum likelihood parameter estimation by sequential testing (ML-PEST), Mills-Nithi (MN), supervised parametric estimation (SPE)—and 2 visual methods: RR visual and ML-PEST visual. Methods: In this observational study, RMT was estimated in 20 healthy participants using 6 approaches: 4 EMG-based (RR, ML-PEST, MN, SPE) and 2 visual (RR and ML-PEST). We assessed agreement among EMG-based methods and compared RMT estimates and trial counts across all methods. Results: EMG-based methods showed strong agreement (ICC: 0.97, 95% CI: 0.94-0.99). RMT estimates differed significantly ( P =0.001), with RR Visual yielding the highest values—significantly higher than RR EMG, ML-PEST EMG, and SPE EMG methods. Trial counts also varied ( P <0.001), with ML-PEST requiring the fewest. In subgroup analysis, RR Visual and ML-PEST Visual produced similar RMTs, but ML-PEST Visual needed fewer trials. Conclusions: Adaptive threshold-hunting methods like ML-PEST offer efficient and accurate RMT estimation while reducing the number of required trials, supporting their use in both clinical and research applications.
Electroconvulsive therapy (ECT) is an established treatment strategy for a range of psychiatric disorders, including depression, mania, psychosis, and catatonia. A growing body of evidence suggests that ECT may affect motor symptoms in movement disorders. In a systematic review, we aim to review the evidence on the use of ECT in movement disorders. We searched PubMed, SCOPUS, Cochrane, Web of Science, and Embase to identify relevant publications. Fifty-eight papers were retained for data extraction. The existing evidence suggests a beneficial impact of ECT on both motor and nonmotor symptoms across various movement disorders, with the most substantial findings reported for Parkinson disease. Conversely, the evidence pertaining to Huntington disease and related disorders cannot rule out a potentially negative effect. Given that the data reviewed are constrained in both quantitative and qualitative rigor, predominantly derived from case reports, further research through the publication of case reports and the conduct of standardized clinical trials is warranted.
