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.

This study aims to explore perspectives of patients, family, and healthcare professionals on feasibility of family presence during electroconvulsive therapy (ECT). This qualitative study used semistructured interviews. Eleven patients and 12 healthcare workers participated in small focus groups. Four family members were interviewed individually. All patients and their family members had prior experience with ECT, and all healthcare workers provided care to patients undergoing ECT. Verbatim transcriptions were analyzed using reflexive thematic analysis. Five main themes emerged. First, family members should be considered as partners in ECT care and their involvement is beneficial for patients, family, and healthcare workers. Second, patients can experience more support through family proximity immediately before and after ECT and during the ECT procedure by providing an added sense of control. Third, family presence can be stressful for family members as witnessing the procedure might be anxiety provoking. In addition, for healthcare workers, increased distress by feeling watched might negatively impact their professional performance. Fourth, all participants express the need for clear guidelines when implementing family presence during ECT. Fifth, more transparency through family presence might be helpful to dispel ECT myths still present in society. Even though family presence during an ECT procedure can be stressful for healthcare workers and families, it can be feasible when embedded in a broader family-centered ECT care including clear guidelines. Family presence may enhance patients' sense of support, improve understanding of ECT for both patients and family members, and help destigmatize the procedure.

OBJECTIVE:We aimed to synthesize the evidence on confusional states and neurocognitive changes associated with the concurrent use of lithium and electroconvulsive therapy (ECT). METHODS:We conducted a systematic search of PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, CINAHL, PsycArticles, and clinical trials registries up to September 2025. Eligible studies compared the incidence of confusional states or changes in neurocognitive test scores in patients receiving lithium and ECT (Li-ECT) and those receiving ECT without lithium. We performed separate meta-analyses and calculated odds ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes and standardized mean differences (SMD) for continuous outcomes. Additionally, case reports describing cognitive effects of Li-ECT were synthesized. RESULTS:Sixteen studies were included: 11 studies (n = 66,156) assessed confusional states and five (n = 341) evaluated neurocognitive changes. The Restricted Maximum-Likelihood meta-analysis showed no significant association between lithium use and confusional states (OR 2.09; 95% CI: 0.94-4.66; p = 0.07), whereas a Paule-Mandel sensitivity analysis suggested a significant association (OR 2.38; 95% CI: 1.20-4.74; p = 0.01). No significant differences were observed in changes in global cognitive functioning, autobiographical memory or verbal fluency test scores ([SMD = 0.25; 95% CI: -0.98-1.49; p = 0.69], [SMD = 0.27; 95% CI: -1.37; 1.9; p = 0.75], [SMD = -0.89; 95% CI: -3.18; 1.39; p = 0.44]). CONCLUSION:Current evidence does not show a significant increase in cognitive side effects associated with lithium use during ECT. However, methodological limitations, sensitivity to meta-analytic assumptions and clinical heterogeneity preclude definitive conclusions. Large prospective studies using standardized cognitive assessments are needed to confirm the tolerability of concurrent lithium and ECT use. While our findings support the cautious continuation of lithium during ECT, individualized clinical decision-making remains crucial to maximize efficacy and minimize cognitive burden.

INTRODUCTION:Electroconvulsive therapy (ECT) is among the most effective treatments for severe depression, yet determining who will benefit remains challenging due to the lack of reliable predictors of treatment response. While clinical characteristics such as higher age and psychotic features are associated with increased odds of treatment success, their limited predictive value underscores the need for multimodal prediction models that integrate biological markers. Identifying such predictive biomarkers could facilitate a more personalized treatment strategy, optimize patient selection and increase ECT response rates. METHODS:In this prospective cohort study (n = 74), we developed multivariable linear and logistic regression models to assess the predictive value of plasma immune markers and their added contribution to clinical prediction models for ECT outcomes. Depressive symptom reduction was measured using the Inventory of Depressive Symptomatology (IDS-C). RESULTS:Kynurenic acid (KYNA) emerged as a significant predictor of the percentage symptom reduction and remission after ECT and significantly improved the prediction of response when added to clinical predictors. Subgroup analyses revealed stronger predictive value for KYNA in unipolar depression, males, and patients without comorbid inflammation (i.e., without acute infections or chronic inflammatory disease), suggesting its relevance in specific patient populations. CONCLUSION:KYNA shows promise as a predictive biomarker for ECT outcomes. Future research should validate its robustness across diverse cohorts and patient subgroups to enable its clinical integration into personalized treatment strategies.

Nitrous oxide is being investigated as a treatment for therapy-resistant depression, yet its environmental implications as a potent greenhouse gas are largely unaddressed. A single 1 h treatment generates ∼150 kg CO2-equivalents, rising to ∼7.8 t per patient-year, highlighting the need to incorporate environmental externalities into evaluation.

BackgroundPreventing relapse following a successful acute treatment of major depressive disorder (MDD) remains a clinical challenge. The presence of residual depressive symptoms seems to be a reliable predictor of relapse. However, few studies have systematically evaluated the relative contribution of specific residual symptoms to relapse risk.ObjectiveThis review synthesizes studies investigating the association between individual residual depressive symptoms and relapse risk following a successful acute treatment of MDD.MethodsA scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A systematic literature search was performed using terms related to depression, residual symptoms and relapse.ResultsEleven studies were included. Residual sleep disturbance and anxiety showed a statistically significant association with increased relapse risk in most studies assessing these symptoms. Most studies assessing residual fatigue, appetite, weight change, depressed mood or diminished interest did not observe statistically significant associations with relapse risk. Findings regarding agitation or restlessness and decreased libido were mixed, with some studies reporting statistically significant associations while others did not. A variety of symptom rating scales was used to assess residual depressive symptoms, resulting in substantial heterogeneity.ConclusionSpecific residual depressive symptoms, notably sleep disturbance and anxiety, may serve as predictors of increased relapse risk and should alert clinicians. However, substantial heterogeneity across studies limits the consistency and generalizability of these findings. Standardized and multidimensional assessment strategies, integrating both clinician-rated and self-report instruments, are needed to comprehensively capture the residual symptom burden and improve relapse risk prediction.

INTRODUCTION:Postictal agitation (PIA) is an impactful confusional state occasionally occurring after electroconvulsive therapy (ECT). PIA creates dangerous situations for caregivers and patients, prolongs lead times, and sometimes leads to the premature discontinuation of ECT. Despite the impact PIA can have on patients and caregivers, little is known about its incidence and the factors associated with its occurrence. This study aims to investigate putative prognostic factors for PIA. METHODS:We utilized data from the "Rivastigmine for ECT-induced Cognitive Adverse effects in Late-Life depression" (RECALL) prospective cohort study; a study on older adults (≥ 55 years) with a major depressive episode receiving ECT. We investigated several putative prognostic factors based on previous research, biological plausibility, and availability. PIA was defined by either a Richmond Agitation-Sedation score ≥ 2 or the administration of emergency medication specifically for PIA. Mixed-effects logistic regression was used to analyze univariate and adjusted odds ratios for the prognostic factors. RESULTS:We included 142 patients who received 1838 ECT sessions. The incidence of PIA was 34.5% at the patient-level and 9.2% at the session-level. A small subset of older adults (19.7%) accounted for 87.5% of all PIA occurrences. We found that male sex, flumazenil use, and a longer seizure duration were associated with higher odds of developing PIA. Multi-seizure sessions and a higher level of education were associated with lower occurrence of PIA. CONCLUSION:This study identified sex, flumazenil use, seizure duration, the amount of seizures during a session, and education level as prognostic factors for PIA. The pronounced clustering of PIA events within a small subset of patients suggests meaningful interindividual vulnerability, but should be replicated in future studies. If confirmed, these findings could provide actionable insights for preventive treatment strategies. In particular, the use of flumazenil should be critically reconsidered in persons experiencing PIA. TRIAL REGISTRATION:EudraCT 2014-003385-24.

BACKGROUND:Depression is increasingly understood as a complex dynamic network of individual depressive symptoms that change over time and are causally related to each other. Directed dynamic time warping (DTW) is a novel method for examining the temporal pattern of symptom change, hereby identifying symptoms that tend to remit earlier and those that improve at later stages of treatment. We compared directed depressive symptom dynamics across psychotherapy, pharmacotherapy and electroconvulsive therapy (ECT). METHODS:Time series data from three observational studies (on ECT) and two randomized trials (one on pharmacotherapy and one on psychotherapy) were included, comprising a total of 549 patients. Across these cohorts, individual depressive symptoms were assessed using validated depressive symptom rating scales. Time series data were analyzed using DTW to calculate a directed symptom network yielding the temporal lead or temporal lag for each symptom. RESULTS:Patients were on average 62 years old and 60% were female. The dynamic symptom changes were largely similar across all treatment modalities. Somatic symptoms and suicidal ideation showed significant temporal lead, indicating that remission of these symptoms tended to precede remission of other symptoms. Mood symptoms showed the strongest temporal lag values, suggesting that remission of these symptoms tended to occur last during treatment. CONCLUSION:The current results suggest that improvements in depressive mood symptoms are preceded by improvements in somatic symptoms and suicidal ideation, irrespective of treatment modality. This may have some important clinical implications. Future research, however, should elucidate whether baseline symptom severity affects the directed DTW network.

OBJECTIVE:For decades, a persistent claim has been that autobiographical memory loss after electroconvulsive therapy (ECT) for depression might actually contribute to ECT efficacy by reducing or even eliminating autobiographical memories. To test this claim, the primary aim of this study is to examine the association between autobiographical memory loss and remission of depression. The hypothesis is that remitted patients have more autobiographical memory loss after ECT compared to non-remitted patients. METHODS:In 71 patients with major depressive disorder undergoing ECT, autobiographical memory consistency (Kopelman Autobiographical Memory Interview) and depression severity (Montgomery-Åsberg Depression Rating Scale) were assessed before and within 1 week after treatment. Logistic regression analyses were conducted to examine the association between both autobiographical memory loss (i.e., memory consistency) and remission (MADRS < 10), including age, episode duration, baseline MADRS score, and treatment condition as covariates. RESULTS:All logistic regression models were significant. The overall autobiographical memory consistency-score (OR = 1.072, 95% CI [1.018-1.130], p = 0.009) and the consistency-score for recent memories (OR = 1.043, 95% CI [1.006-1.082], p = 0.021) were significantly associated with the odds of remission but in the opposite direction of the hypothesis. A higher age and shorter episode duration further increased the likelihood of remission. Additionally, post hoc analyses showed that the trajectories of autobiographical memory performance over time differed between remitters and non-remitters, indicating a slight decrease in autobiographical memories for more recent events in non-remitters and no change in remitters. CONCLUSIONS:This study shows that, contrary to the hypothesis, remitted patients have less autobiographical memory loss, particularly for recent memories than non-remitters. This refutes the premise that the loss of autobiographical memories contributes to the therapeutic effectiveness of ECT.

BACKGROUND:Melatonin emerged as a new potential therapeutic agent for the treatment of mood and anxiety disorders. Existing randomized controlled trials (RCTs) have predominantly focused on the immediate effects of melatonin, leaving a knowledge gap concerning its long-term effects. OBJECTIVES:To conduct a scoping review of the literature in order to collect long-term (≥ 3 months) efficacy and tolerability data of melatonin (agonists) in children, adults, or the elderly with anxiety, depressive, or bipolar disorder. METHODS:A systematic literature search of PubMed, Embase, Web of Science, Scopus, and CENTRAL electronic databases was conducted for English or Dutch-language RCTs. Additionally, 3 electronic databases were screened for unpublished clinical trials. RESULTS:Six hundred sixty-one records were identified as possibly eligible. Of these, six met the inclusion criteria. Although some studies have demonstrated a significant positive long-term effect of melatonin on mood or anxiety symptoms, most have not. In general, the use of melatonin is associated with mild adverse events. CONCLUSIONS:Long-term efficacy data of melatonin (agonists) in patients with mood or anxiety disorders are scarce and inconsistent. There is insufficient long-term data allowing a thorough evaluation of its safety profile.

BackgroundElectroconvulsive therapy (ECT) is an effective treatment for severe depression, mania, psychosis and catatonia. While seizures are considered essential for the therapeutic effect of ECT, it concurrently has an anticonvulsant effect which plays a role in its mechanism of action. This property has also prompted the use of ECT in managing status epilepticus (SE).Case PresentationWe report two distinct cases of prolonged seizures during ECT that persisted for more than 5 min despite administration of propofol and lorazepam, ultimately meeting criteria for status epilepticus (SE). The first case involved an 80-year old woman with severe psychotic depression starting ECT, while the second case involved a 30-year old man receiving maintenance ECT for difficult-to-treat schizophrenic psychosis. In both cases, SE was promptly terminated by restimulation, defined as an additional stimulus delivered within the same ECT session. After epilepsy and intracranial pathology were ruled out, ECT was safely resumed in both patients after switching from etomidate to propofol induction.ConclusionStatus epilepticus after ECT can be resolved by restimulation when standard interventions are unsuccessful, thereby avoiding potential neurological complications. We provide an overview of the mechanism and current clinical evidence supporting this strategy, and propose an amended clinical practice protocol for SE after ECT.

Posttraumatic stress disorder (PTSD) is associated with a high burden of disability and mortality. Despite standard treatments with antidepressants and/or psychotherapy, remission is often difficult to achieve. Electroconvulsive therapy (ECT) is an effective treatment for mood disorders but is currently not recognized as a treatment modality for PTSD. The literature about its potential role in the management of PTSD is growing. Thus, we aim to systematically review the available evidence for the role of ECT in PTSD.Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guidelines, we performed a systematic literature search from 1958 to December 2023 using PubMed, Embase, Web of Science, Cochrane Central Register of Controlled trials databases, and the Clinicaltrials.gov-registry.Eighteen studies met our inclusion criteria: 1 meta-analysis, 2 randomized control trials, 2 prospective, 4 retrospective studies, 8 case reports, and 2 reviews.Accumulating evidence suggests that ECT might have a beneficial effect on the core symptoms of PTSD with comorbid conditions, such as depression or schizophrenia. Although in some studies, the effect on core PTSD symptoms was not related to an antidepressant effect of ECT, these findings need further replication. Nevertheless, in severe and intractable cases, ECT can be considered, especially in the presence of comorbid depression. Further research in patients without comorbidity is warranted.

Electroconvulsive therapy (ECT)-mediated hippocampal volumetric increase is consistently reported, though its clinical relevance remains debated. This study evaluates if ECT-related cognitive side effects are associated with regional volumetric changes along the hippocampal longitudinal axis. Longitudinal T1-weighted MRI scans in 435 patients (54.0 ± 15.0 years, 261 female) with major depression from the Global ECT-MRI Research Collaboration (GEMRIC) were used to measure changes in right global and longitudinal axis hippocampal subdivisions (head, body, tail) from baseline to post-treatment. Cognitive side effects were evaluated using pre-to-post treatment changes in two different verbal fluency tests available for 124 patients. Electric field modelling was applied to explore whether the regional hippocampal electric field strength related to individual changes in cognitive performance. Global hippocampal enlargement is observed pre-to-post ECT (pFDR < 0.001), but enlargement of the hippocampal head significantly exceeds the volumetric change in the hippocampal body and tail (pFDR < 0.001). Volumetric expansion of the hippocampal body and tail significantly associates with reduced verbal fluency scores (pFDR< 0.05). Moreover, volumetric reduction of the hippocampal tail at 6 months post-ECT associates with improved cognitive performance (pFDR < 0.05, N = 24). Finally, patients performing worse on verbal fluency tests following treatment have greater electric field during ECT in the right hippocampal body (puncorrected < 0.05). The findings support that cognitive performance following ECT relates to macrostructural changes in the posterior cognitive hippocampus. Thus, there may be a threshold of ECT induced posterior hippocampal volumetric change, beyond which cognitive side effects occur. Electroconvulsive Therapy (ECT) is a procedure that sends small electric currents through the brain and remains the most effective acute treatment for severe depressive episodes. However, we still do not fully understand how ECT works. Studies using brain scans (MRI) before and after ECT have shown that a part of the brain called the hippocampus often becomes larger after treatment. However, the clinical relevance of the volumetric change remains unknown. In this study, we looked at whether the increase in hippocampus size is linked to cognitive side effects. We found that a larger hippocampal volumetric increase after ECT was associated with reduced performance in verbal fluency tests, which measures our ability to rapidly produce words. These results suggest that big changes in the hippocampus after ECT may be related to short-term cognitive side effects. Ousdal et al. investigate whether global or regional hippocampal volume increase after Electroconvulsive therapy (ECT) for major depressive episodes relate to cognitive side effects. Their findings suggest that pronounced structural change in the posterior hippocampus (i.e., body and tail) associates with reduced cognitive performance following ECT.

The severity of major depressive disorder (MDD) is crucial in guiding treatment decisions for electroconvulsive therapy (ECT), particularly given the high relapse rates post-ECT. Maintenance-ECT (M-ECT) has emerged as a key strategy to prevent relapse, with recent trends favouring symptom-driven approaches. This study explores the use of self-report scales as an adjunct to clinician-rated assessments in M-ECT decision-making, focusing on the Clinician-Rated 30-item Inventory of Depressive Symptomatology (IDS-C) and its self-report version (IDS-SR). In the Preventing Relapse After Successful ECT for Depression (PRASED) study, a subsample of 96 MDD patients were included upon achieving remission after an acute ECT course. Patients were stratified into relapse potential categories based on weekly IDS-C scores, determining the need for zero, one, or two M-ECT sessions the following week. Using five monthly IDS-C and -SR, the scales demonstrated good to excellent agreement, with intraclass correlation coefficients ranging from 0.73 to 0.85 at multiple timepoints during M-ECT. Notably, 81 % of decision-making outcomes were concordant. Also, 16 % would result in patients receiving more ECT sessions based on the IDS-SR than the IDS-C, highlighting some overestimation by self-report scores. These findings indicate that self-assessment of depression severity by IDS-SR is a reliable alternative for clinician-rated measurements during M-ECT. Hence, this reduction of resource burden by self-report could facilitate the widespread implementation of personalised M-ECT, which may improve patient outcomes by reducing relapse rates in MDD. Future research should focus on validating self-report measures as reliable alternatives to clinician assessments in M-ECT to optimize treatment personalization and efficiency.

ObjectiveThere is ongoing concern about the possible negative impact of ECT on neuropsychological functioning, especially on autobiographical memory. In this study we aimed to identify the short- and long-term neuropsychological effects of ECT in the domain of memory.MethodsTwenty-eight patients aged 18 years and older with a unipolar or bipolar depression, referred for ECT, were eventually included. The neuropsychological test battery assessed verbal memory, verbal fluency, and autobiographical memory. The battery was administered prior to ECT, 1 week, and 3 months after the last ECT session. We compared the neuropsychological performances of our sample with normative data from a healthy population.ResultsAfter adjusting for covariates, performance on tasks assessing verbal memory, verbal fluency, and autobiographical memory showed a significant decline during ECT. However, test scores significantly improved following the completion of ECT. Additionally, patients with higher QIDS-CR scores consistently demonstrated lower performance on the verbal fluency task across all time points. No significant association was found between the total number of ECT sessions and changes in test scores during or after treatment. 3 months after ending ECT, cognitive functioning returned to pretreatment levels of performance. We found that patients with a depressive episode performed significantly worse on task measuring verbal memory and fluency at every time point as compared to a healthy population.ConclusionOur results show that a course of ECT in patients with a depressive episode influences verbal memory, autobiographical memory and verbal fluency. Neuropsychological performances significantly declined during ECT. Following ECT, neuropsychological performances, as compared to during ECT, were significantly improved and were equivalent to baseline. However, neuropsychological performance remains poor as compared to a healthy population.

OBJECTIVE:This study aims to explore perspectives of patients, family, and healthcare professionals on feasibility of family presence during electroconvulsive therapy (ECT). METHODS:This qualitative study used semistructured interviews. Eleven patients and 12 healthcare workers participated in small focus groups. Four family members were interviewed individually. All patients and their family members had prior experience with ECT, and all healthcare workers provided care to patients undergoing ECT. Verbatim transcriptions were analyzed using reflexive thematic analysis. RESULTS:Five main themes emerged. First, family members should be considered as partners in ECT care and their involvement is beneficial for patients, family, and healthcare workers. Second, patients can experience more support through family proximity immediately before and after ECT and during the ECT procedure by providing an added sense of control. Third, family presence can be stressful for family members as witnessing the procedure might be anxiety provoking. In addition, for healthcare workers, increased distress by feeling watched might negatively impact their professional performance. Fourth, all participants express the need for clear guidelines when implementing family presence during ECT. Fifth, more transparency through family presence might be helpful to dispel ECT myths still present in society. CONCLUSIONS:Even though family presence during an ECT procedure can be stressful for healthcare workers and families, it can be feasible when embedded in a broader family-centered ECT care including clear guidelines. Family presence may enhance patients' sense of support, improve understanding of ECT for both patients and family members, and help destigmatize the procedure.