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In the early 1960s, a climate of public condemnation of electroconvulsive therapy was emerging in the USA and Europe. In spite of this, the electroshock apparatus prototype, introduced in Rome in 1938, was becoming hotly contended. This article explores the disputes around the display of the electroshock apparatus prototype in the summer of 1964 and sheds new light on the triangle of personalities that shaped its future: Karl and William Menninger, two key figures of American psychiatry in Topeka; their competitor, Adalberto Pazzini, the founder of the Sapienza Museum of the History of Medicine in Rome; and, between them, Lucio Bini, one of the original inventors of ECT, who died unexpectedly that summer.

Background: Electroconvulsive therapy (ECT) is the most effective treatment option for major depressive disorder, so understanding whether its clinical effect relates to structural brain changes is vital for current and future antidepressant research., Objective: To determine whether clinical response to ECT is related to structural volumetric changes in the brain as measured by structural magnetic resonance imaging (MRI) and, if so, which regions are related to this clinical effect. We also determine whether a similar model can be used to identify regions associated with electrode placement (unilateral versus bilateral ECT)., Methods: Longitudinal MRI and clinical data (Hamilton Depression Rating Scale) was collected from 10 sites as part of the Global ECT-MRI research collaboration (GEMRIC). From 192 subjects, relative changes in 80 (sub)cortical areas were used as potential features for classifying treatment response. We used recursive feature elimination to extract relevant features, which were subsequently used to train a linear classifier. As a validation, the same was done for electrode placement. We report accuracy as well as the structural coefficients of regions included in the discriminative spatial patterns obtained., Results: A pattern of structural changes in cortical midline, striatal and lateral prefrontal areas discriminates responders from non-responders (75% accuracy, p < 0.001) while left-sided mediotemporal changes discriminate unilateral from bilateral electrode placement (81% accuracy, p < 0.001)., Conclusions: The identification of a multivariate discriminative pattern shows that structural change is relevant for clinical response to ECT, but this pattern does not include mediotemporal regions that have been the focus of electroconvulsive therapy research so far., Competing Interests: Declaration of competing interest The authors report no conflict of interest., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Although electroconvulsive therapy seizure duration has been shown to have limited relevance to efficacy, seizure duration remains important for clinically valid stimulus efficiency. There has been no report on seizure duration using sample entropy with Thymatron (Somatics, Inc), which is widely used in Japan. Furthermore, wavelet transform analysis is also suitable for a seizure because of the wide range of dominant frequencies. Therefore, in this study with Thymatron, the intraclass correlations of seizure duration determined by sample entropy, wavelet transform, and visual determination were investigated to determine whether these methods were applicable for clinical use. Wavelet transform, sample entropy, and the human rater had high intraclass correlations for seizure duration. The present results indicate that wavelet transform and sample entropy can be useful in the clinical electroconvulsive therapy setting, and they may also be suitable for clinical research into the mechanisms of the generalized tonic-clonic seizures related to the efficacy of electroconvulsive therapy., (© 2019 The Authors. Neuropsychopharmacology Reports published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Society of NeuropsychoPharmacology.)

Transcranial electrical stimulation (tES) aims to alter brain function non-invasively by applying current to electrodes on the scalp. Decades of research and technological advancement are associated with a growing diversity of tES methods and the associated nomenclature for describing these methods. Whether intended to produce a specific response so the brain can be studied or lead to a more enduring change in behavior (e.g. for treatment), the motivations for using tES have themselves influenced the evolution of nomenclature, leading to some scientific, clinical, and public confusion. This ambiguity arises from (i) the infinite parameter space available in designing tES methods of application and (ii) varied naming conventions based upon the intended effects and/or methods of application. Here, we compile a cohesive nomenclature for contemporary tES technologies that respects existing and historical norms, while incorporating insight and classifications based on state-of-the-art findings. We consolidate and clarify existing terminology conventions, but do not aim to create new nomenclature. The presented nomenclature aims to balance adopting broad definitions that encourage flexibility and innovation in research approaches, against classification specificity that minimizes ambiguity about protocols but can hinder progress. Constructive research around tES classification, such as transcranial direct current stimulation (tDCS), should allow some variations in protocol but also distinguish from approaches that bear so little resemblance that their safety and efficacy should not be compared directly. The proposed framework includes terms in contemporary use across peer-reviewed publications, including relatively new nomenclature introduced in the past decade, such as transcranial alternating current stimulation (tACS) and transcranial pulsed current stimulation (tPCS), as well as terms with long historical use such as electroconvulsive therapy (ECT). We also define commonly used terms-of-the-trade including electrode, lead, anode, and cathode, whose prior use, in varied contexts, can also be a source of confusion. This comprehensive clarification of nomenclature and associated preliminary proposals for standardized terminology can support the development of consensus on efficacy, safety, and regulatory standards., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Electroconvulsive therapy (ECT) is a highly effective treatment for severe psychiatric disorders. Despite its high efficacy, the use of ECT would be greater if the risk of cognitive side effects were reduced. Over the last 20 years, developments in ECT technique, including improvements in the dosing methodology and modification of the stimulus waveform, have allowed for improved treatment methods with reduced adverse cognitive effects. There is increasing evidence that the electrode placement is important for orienting the electrical stimulus and therefore modifying treatment outcomes, with potential for further improvement of the placements currently used in ECT., Objective: We used computational modelling to perform an in-depth examination into regional differences in brain excitation by the ECT stimulus for several lesser known and novel electrode placements, in order to investigate the potential for an electrode placement that may optimise clinical outcomes., Methods: High resolution finite element human head models were generated from MRI scans of three subjects. The models were used to compare regional differences in average electric field (EF) magnitude among a total of thirteen bipolar ECT electrode placements, i.e. three conventional placements as well as ten lesser known and novel placements., Results and Conclusion: In this exploratory study on a systemic comparison of thirteen ECT electrode placements, the EF magnitude at regions of interest (ROIs) was highly dependent upon the position of both electrodes, especially the ROIs close to the cortical surface. Compared to conventional right-unilateral (RUL) ECT using a temporo-parietal placement, fronto-parietal and supraorbito-parietal RUL also robustly stimulated brain regions considered important for efficacy, while sparing regions related to cognitive functions, and may be a preferrable approach to the currently used placement for RUL ECT. The simulations also found that regional average EF magnitude varied between individual subjects, due to factors such as head size, and results also depended on the size of the defined ROI., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

The Food and Drug Administration (FDA) is issuing a final order to reclassify the electroconvulsive therapy (ECT) device for use in treating catatonia or a severe major depressive episode (MDE) associated with major depressive disorder (MDD) or bipolar disorder (BPD) in patients age 13 years and older who are treatment-resistant or who require a rapid response due to the severity of their psychiatric or medical condition, which is a preamendments class III device, into class II (special controls). FDA is also issuing this final order to require the filing of a premarket approval application (PMA) or a notice of completion of a product development protocol (PDP) for the preamendments class III ECT devices for all other uses that are not being reclassified to class II (product code GXC).

The Food and Drug Administration (FDA, the Agency, or we) is issuing a final rule to amend its regulations governing classification and reclassification of medical devices to conform to the applicable provisions of the Federal Food, Drug, and Cosmetic Act (FD&C Act) as amended by the Food and Drug Administration Safety and Innovation Act (FDASIA). FDA is also making additional changes unrelated to the FDASIA requirements, to update its regulations governing the classification and reclassification of medical devices. FDA is taking this action to codify the procedures and criteria that apply to the classification and reclassification of medical devices and to provide for classification of devices in the lowest regulatory class consistent with the public health and the statutory scheme for device regulation.

Early identification of patients at high risk for an unfavorable outcome to ECT during the course might be beneficial because it provides an opportunity for timely intensification or optimization of stimulus conditions. We aimed to develop a new Seizure Quality Index (SQI) that delivers a clinical relevant outcome prediction early in the treatment course and can be used within common clinical setting. An observational study was conducted. Patients (n = 86) with a depressive episode and the clinical decision for ECT (right unilateral, brief pulse) were included, and several ictal parameters derived from the second ECT session and the clinical outcome of the patients were documented. Optimal cut-off points for five different domains of ictal adequacy for younger and older patients for the prediction of "non-response" and "non-remission" based on seizure quality was determined by the Youden Index and a sum score was built. Logistic regression analyses tested the predictive power of derived models. For both outcome variables "non-response" and "non-remission", the logistic regression models were statistically significant, albeit for remission only for subjects below the age of 65 years (χ 2  = 17.9, p = 0.001) and (χ 2  = 6.4, p = 0.020), respectively. The models correctly classified 87.2% (non-response) and 50.0% (non-remission) of the cases. ROC curve analysis showed an AUC of 0.87 (non-response) and 0.70 (non-remission). In elderly patients (> 65), no such model could be established due to a response rate of 100%. Our data provide promising, clinically relevant results about the prediction of response to ECT at an early stage for patients with depression.

Epilepsy is often associated with comorbid psychiatric illnesses that can significantly impact its long-term course. The most frequent of these psychiatric comorbidities is major depressive disorder, which affects an estimated 40% of patients with epilepsy. Many patients are underdiagnosed or undertreated, yet managing their mood symptoms is critical to improving their outcomes. When conventional psychiatric treatments fail in the management of depression, neuromodulation techniques may offer promise, including electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), and repetitive transcranial magnetic stimulation (rTMS), as discussed in this review. "This article is part of the Supplement issue Neurostimulation for Epilepsy.", (Published by Elsevier Inc.)

Outcome Objectives: METHODS: This is a case report of a patient who underwent placement and initiation of a hypoglossal nerve stimulator device in the context of receiving electroconvulsive therapy for bipolar depression between February and September 2016. To our knowledge, this has not yet been reported in the literature. Outcome measurements included successful device activation and successful device use throughout electroconvulsive therapy., Results: The patient underwent successful device implantation, activation, and use without disruption throughout electroconvulsive therapy sessions. No special device deactivation was required during electroconvulsive therapy sessions., Conclusion: Obstructive sleep apnea is a common disorder that causes significant reduction in quality of life and is an independent risk factor for multiple comorbidities. Electroconvulsive therapy is an established treatment for medication-refractory depression with minimal risk in most patient populations. This is the first report in the literature of a patient undergoing ECT for bipolar depression with recent activation of Inspire hypoglossal nerve stimulator who had no disruption in the function of his implanted device., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Electroconvulsive seizure (ECS) is an experimental animal model of electroconvulsive therapy, the most effective treatment for severe depression. ECS induces generalized tonic-clonic seizures with low mortality and neuronal death and is a widely-used model to screen anti-epileptic drugs. Here, we describe an ECS induction method in which a brief 55-mA current is delivered for 0.5 s to male rats 200 - 250 g in weight via ear-clip electrodes. Such bilateral stimulation produced stage 4 - 5 clonic seizures that lasted about 10 s. After the cessation of acute or chronic ECS, most rats recovered to be behaviorally indistinguishable from sham "no seizure" rats. Because ECS globally elevates brain activity, it has also been used to examine activity-dependent alterations of synaptic proteins and their effects on synaptic strength using multiple methods. In particular, subcellular fractionation of the postsynaptic density (PSD) in combination with Western blotting allows for the quantitative determination of the abundance of synaptic proteins at this specialized synaptic structure. In contrast to a previous fractionation method that requires large amount of rodent brains, we describe here a small-scale fractionation method to isolate the PSD from the hippocampi of a single rat, without sucrose gradient centrifugation. Using this method, we show that the isolated PSD fraction contains postsynaptic membrane proteins, including PSD95, GluN2B, and GluA2. Presynaptic marker synaptophysin and soluble cytoplasmic protein α-tubulin were excluded from the PSD fraction, demonstrating successful PSD isolation. Furthermore, chronic ECS decreased GluN2B expression in the PSD, indicating that our small-scale PSD fractionation method can be applied to detect the changes in hippocampal PSD proteins from a single rat after genetic, pharmacological, or mechanical treatments.

Introduction: The influence of age and gender in the electrical charge delivered in a given population was analysed using an electroconvulsive therapy (ECT) clinical database., Material and Method: An observational, prospective, longitudinal study with descriptive analysis was performed using data from a database that included total bilateral frontotemporal ECT carried out with a Mecta spECTrum 5000Q ® in our hospital over 6 years. From 2006 to 2012, a total of 4,337 ECT were performed on 187 patients. Linear regression using mixed effects analysis was weighted by the inverse of the number of ECT performed on each patient per year of treatment., Results: The results indicate that age is related with changes in the required charge (P=.031), as such that the older the age a higher charge is needed. Gender is also associated with changes in charge (P=.014), with women requiring less charge than men, a mean of 87.3mC less. When the effects of age and gender are included in the same model, both are significant (P=.0080 and P=.0041). Thus, for the same age, women require 99.0mC less charge than men, and in both genders the charge increases by 2.3mC per year., Conclusions: From our study, it is concluded that the effect of age on the dosage of the electrical charge is even more significant when related to gender. It would be of interest to promote the systematic collection of data for a better understanding and application of the technique., (Copyright © 2015 SEP y SEPB. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Optimising ventilation control in the anaesthetic process of electroconvulsive therapy (ECT) can be a method for improving the effectiveness and safety of some treatments. There are several approaches for inducing adequate therapeutic seizures in patients with medical co-morbidity or in those with high seizure thresholds, although all of them present limitations. A new approach is hyperventilation with laryngeal mask, a method that improves oxygenation, achieves hypocapnia, and lowers seizure threshold. Thus, hyperventilation with laryngeal mask could, hypothetically, be useful to decrease the energy needed to obtain adequate therapeutic seizures., Material and Methods: A randomized crossover study was conducted on 14 patients on maintenance ECT, using a laryngeal mask versus a facemask. When laryngeal masks were applied, the energy was reduced by 45% compared with the energy required when ventilated with facemasks (performed with standard dose)., Results: The results of the study revealed that, despite a 45% energy reduction with laryngeal mask, there were no significant differences in seizure length in either group., Conclusions: These results prompt us to propose ventilation with laryngeal mask as an alternative to decrease energy applied without lowering seizure times. This is a preliminary study with a small sample, which opens new lines of research. Larger samples and other measurements of seizure adequacy are needed in future studies, in order to study possible improvements in ventilation and minimising adverse effects of ECT, especially in patients with medical co-morbidities., (Copyright © 2016. Publicado por Elsevier España, S.L.U.)

Objective: The aim of the study was to survey the media landscape to determine whether visual depictions of electroconvulsive therapy (ECT) are becoming more or less medically accurate in the new millennium., Method: English-language film and television shows depicting ECT were analyzed for patient demographics, administrator roles, indication, consent, anesthesia, paralytics, bite block, lead placement, electroencephalogram, and outcome., Results: Thirty-nine ECT scenes were viewed, and just 3 included all 5 essential tools of modern ECT: anesthesia, paralytic, electrodes, electroencephalogram, and a bite block., Conclusions: Media depictions of ECT do not reflect current practice. Too often, ECT is portrayed as a torture technique rather than an evidenced-based therapy, and even in a therapeutic setting, it is too often shown with outdated techniques.

Modern electroconvulsive therapy devices are largely trouble free but will periodically malfunction. We present a systematic approach to correction of a failure in the electroencephalogram recording capability of our Thymatron System IV machine.

Background: An individualized approach to maximize electroconvulsive therapy (ECT) efficacy and minimize cognitive side effects is to treat patients relative to their seizure threshold (ST). However, although Right Unilateral-Ultrabrief (0.3 ms) (RUL-UB) ECT is increasingly used in clinical settings as an effective form of ECT with minimal cognitive effects, there is sparse data regarding predictors of ST., Objective: To analyze the relationship between ST and clinical and demographic factors in a sample of patients treated with RUL-UB ECT., Methods: Clinical, demographic and ECT data from 179 patients in ECT research studies were examined. Seizure threshold was titrated at the first ECT session. ECT was performed with a Thymatron(®) or Mecta(®) device, with thiopentone (2.5-5 mg/kg) or propofol (1-2 mg/kg) anaesthesia. Medications taken at the time of ST titration were documented. The association between ST and candidate predictor variables was examined with regression analysis., Results: Multiple regression analyses showed that 34% of the variance in ST (P < 0.001) could be predicted. Older age (R(2) = 0.194, P < 0.001), propofol (vs thiopentone) (R(2) = 0.029, P ≤ 0.01) and higher anaesthetic dose (mg in propofol equivalents) (R(2) = 0.029, P < 0.05) were found to be predictors of higher initial ST. Treatment with lithium (R(2) = 0.043, P < 0.01) and study site (R(2) = 0.019, P < 0.05) significantly predicted lower initial ST., Conclusions: Empirical titration is recommended for accurate determination of ST in patients receiving RUL-UB ECT. Novel findings of this study are that propofol anaesthesia resulted in higher ST than thiopentone and concomitant treatment with lithium treatment lowered ST., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: Evidence supports the use of electroconvulsive therapy (ECT) in current practice, and good quality of care is related to adherence to evidence-based guidelines. However, there are no guidelines for the practice of ECT in Nigeria and there is no regulatory body for its standards. The objective of this study therefore was to examine the practice of ECT between 2001 and 2010 at the Neuropsychiatric Hospital, Aro, Abeokuta, regarding consent procedures, staffing, training, indications, and administration with the goal of informing the development of guidelines locally., Methods: Data were extracted from 154 complete ECT treatment records in the register and from the patients' case files. The data were qualitatively analyzed and described., Results: The mean age of patients who received ECT was 35.5 years and the majority were female. Bilateral electrode placement was invariable for all treatments. The major diagnosis of the patients receiving ECT was schizophrenia, whereas poor response to medication and psychomotor retardation were commonly stated indications. Treatments were largely unmodified during the first 3 years of the review, with a gradual reversal of this pattern in the latter years. The mean number of treatments per patient was 6.6, and only 1 patient received continuation ECT., Conclusions: Although the procedure of ECT in this center is generally similar to what is obtained in many other countries in Asia and Africa, aspects such as that of informed consent require attention. Regular audits of the practice are desirable.

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.

Objective: Electroconvulsive therapy (ECT) is the most effective treatment for major depression. Brief pulse width (BPW; pulse width, 1.0 m/s) ECT is often associated with cognitive impairment. Ultrabrief (UB; pulse width, 0.3 m/s) ECT is better tolerated and causes less cognitive impairment so has been introduced as an alternative. Previous research has shown that more treatments are needed with UB ECT; however, there has not been any previous research into the impact of prescribing UB ECT on length of stay., Methods: This study reports naturalistic data collected from 258 inpatients in a private psychiatric hospital for 2 years since the introduction of UB ECT. Clinician and self-rated scales of depression severity and hospital service data were used to evaluate the number of ECT treatments, length of stay, and efficacy., Results: Patients prescribed UB ECT had, on average, 10.9 treatments compared to 8.8 for BPW ECT. They also spent more time in hospital; 30.3 days from the first ECT treatment to discharge compared to 24.7 days for patients prescribed BPW ECT. Excluding patients who switched treatments, 54% of patients prescribed UB ECT responded compared to 66.7% of patients prescribed BPW ECT. More patients (n = 42) switched from UB to BPW than from BPW to UB (n = 3). In the 4 years since the introduction of UB ECT, the number of patients prescribed ECT has increased, and the mean number of treatments per patient (for all patients receiving ECT) has increased from 7.7 to 11.6., Conclusions: Ultrabrief ECT has significant advantages, reflected in the increased use of ECT since UB ECT became available. However, the greater number of treatments and the increased length of stay have important implications for service delivery, costs, and bed accessibility.

Objectives: Understanding the relationship between the stimulus parameters of electroconvulsive therapy (ECT) and the electric field characteristics could guide studies on improving risk/benefit ratio. We aimed to determine the effect of current amplitude and electrode size and spacing on the ECT electric field characteristics, compare ECT focality with magnetic seizure therapy (MST), and evaluate stimulus individualization by current amplitude adjustment., Methods: Electroconvulsive therapy and double-cone-coil MST electric field was simulated in a 5-shell spherical human head model. A range of ECT electrode diameters (2-5 cm), spacing (1-25 cm), and current amplitudes (0-900 mA) was explored. The head model parameters were varied to examine the stimulus current adjustment required to compensate for interindividual anatomical differences., Results: By reducing the electrode size, spacing, and current, the ECT electric field can be more focal and superficial without increasing scalp current density. By appropriately adjusting the electrode configuration and current, the ECT electric field characteristics can be made to approximate those of MST within 15%. Most electric field characteristics in ECT are more sensitive to head anatomy variation than in MST, especially for close electrode spacing. Nevertheless, ECT current amplitude adjustment of less than 70% can compensate for interindividual anatomical variability., Conclusions: The strength and focality of ECT can be varied over a wide range by adjusting the electrode size, spacing, and current. If desirable, ECT can be made as focal as MST while using simpler stimulation equipment. Current amplitude individualization can compensate for interindividual anatomical variability.

Introduction: Adolf Bingel, internal medicine specialist, neurologist and psychiatrist, was a pioneer in the establishment of electroconvulsive treatment (ECT) in Germany. Thanks to his dedication, the psychiatric department of the University of Erlangen was Germany's first clinic to offer ECT., Methods: We have analysed relevant archival material and the secondary literature., Results: As a consequence of denazification, Adolf Bingel was classified as a hanger-on by the Tribunal in Heidelberg. In 1946 the accredited German scientist moved to Houston as a "Paperclip-Boy"., Discussion: The ECT-pioneer Bingel has repeatedly been mistaken for the co-inventor of pneumo-encephalograpy, whose name was also Adolf Bingel. This confusion in names has to be corrected., Conclusion: In 1957 Bingel was awarded the title Associate Professor Emeritus by the University of Erlangen. In 1959 he became Associate Professor of Neurology/Baylor University College in Houston/Texas., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: There are minimal data on the use of electroconvulsive therapy (ECT) in adolescents from India. The present study aimed to evaluate the clinical profile and effectiveness of ECT in adolescents (aged 13-18 years)., Methods: A retrospective chart review was carried out to identify adolescents (aged 13-18 years) who had received ECT during the period 1999-2011. During the study period, 39 such patients received ECT; complete records of 25 patients were available. Details regarding their sociodemographic, clinical, and treatment data were extracted from these records for the present study., Results: During the study period, 658 patients received ECT, of which 39 were aged 18 or younger (5.9%). Schizophrenia (n = 14; 56%) was the commonest diagnosis for which ECT was used in adolescents, followed by depression (n = 3; 12%). Catatonic symptoms (n = 17; 68%) were the most common symptoms among these subjects. Electroconvulsive therapy was considered as a treatment of choice taking the clinical picture account in about three fourths of the patients (n = 19; 76%). The mean (SD) numbers of ECTs administered per patient were 10.1 (4.87) (range, 2-21). The mean (SD) response rate to ECT was 76% (23.3%) (range, 31%-100%). Response rates according to diagnosis were the following: 76.3% for schizophrenia, 87.2% for depression, 81.8% for psychosis (not otherwise specified), and 77.7% for acute and transient psychosis. Response rate in patients with catatonia was 91.6%. Prolonged seizures, nausea and vomiting, and headache were reported in 2 cases each., Conclusion: Electroconvulsive therapy is used less frequently in children and adolescents compared to the older patients. This study shows that ECT is effective in the treatment of severe psychiatric disorders in adolescents and is associated with the same frequency of adverse effects as the adults.

Objectives: The objective of this study was to examine the occurrence of laboratory abnormalities and symptoms of central diabetes insipidus (CDI) in patients receiving acute electroconvulsive therapy (ECT) series., Methods: We prospectively investigated adult psychiatric inpatients for objective and subjective evidence of CDI at baseline and after their sixth ECT., Results: Although participants did not report any CDI symptoms, two thirds had clinically important decreases in urine osmolality (>200 mOsm/kg), and two thirds had serum sodium increases of 5 mmol/L following exposure to ECT., Conclusion: Our findings suggest that objective evidence of CDI can occur following the administration of ECT series, even in the absence of symptomatic complaints.

Objectives: To compare the minimum charge to elicit a seizure using 2 different pulse widths, the brief pulse (0.5 milliseconds [ms]) and the ultrabrief pulse (0.3 ms)., Methods: We compared retrospectively the last 30 patients in our ECT unit whose seizure thresholds were titrated using a pulse width of 0.5 ms to the last 30 patients whose seizure thresholds were titrated using a pulse width of 0.3 ms. The former were regular clinical patients, and the latter were participating in a clinical trial on the use of ultrabrief pulse treatment. All titrations were performed with right unilateral electrode positioning. Most patients continued to use psychotropic medications., Results: Initial seizure threshold (as measured in millicoulombs [mC]) for the brief pulse group (0.5 ms) was 16 (n = 1); 32 (n = 21), and 64 (n = 8); whereas for the ultrabrief pulse group (0.3 ms), it was 9.2 (n = 3), 38.4 (n = 21), 19.2 (n = 3), 76.8 (n = 2), and 307.2 (n = 1). Excluding the outlier, there was no statistical difference between mean seizure thresholds., Conclusions: If we exclude the outlier from the ultrabrief group (seizure threshold [ST], 307 mC), we can observe that most of the patients in both groups had an ST between 30 and 40 mC. No patient in the brief pulse group showed a lower ST than 16 mC, probably because this was the first step of titration for this group. The data suggest that the difference between 0.3 and 0.5 ms may not be big, although randomized prospective studies with a more precise and similar steps used for titration are needed. Clinical efficacy was not compared in the present study.

Electroconvulsive therapy (ECT) is a safe and highly effective treatment for management of acute episodes of a variety of serious mental disorders, particularly for major depressive episodes that are resistant to multiple interventions with treatment alternatives. As such, the National Network of Depression Centers (NNDC), a consortium of major academic centers with interest and expertise in this area, believes there is an important public health need for ECT to remain available for clinical use. As with all medical devices, ECT is regulated by the US Food and Drug Administration (FDA), which is presently involved in formulating a proposed rule as to how such devices should be classified. Since such classification may have substantial effects on the availability of ECT to patients for whom it is clinically indicated, the NNDC has reviewed the information provided by the FDA to its Advisory Panel, as well as the subsequent deliberations of the Panel itself at a January 2011 public hearing. This review indicates that the FDA may have substantially underestimated the efficacy of ECT as a means to produce large clinical improvements for individuals suffering from severe major depressive disorders and that such an underestimate likely affected the Panel's willingness to recommend reclassification of ECT devices to a less restrictive category. In addition, the NNDC's review generates support for a variety of methods by which the safety of ECT can be ensured, which is an essential requirement for such reclassification., (© Copyright 2013 Physicians Postgraduate Press, Inc.)

Improper recording electrode placement can cause artifacts on electroconvulsive therapy tracings. This shows an example of electrocardiogram artifact in the electroencephalogram.

Background: Electroconvulsive therapy (ECT) is a highly effective treatment for severe depressive disorder. Efficacy and cognitive outcomes have been shown to depend on variations in electrode placement and other stimulus parameters, presumably because of differences in the pattern of neuronal activation. This latter effect, however, is poorly understood., Objective: In this study, we present an anatomically accurate human head computational model to stimulate neuronal excitation during ECT, to better understand the effects of varying electrode placement and stimulus parameters., Methods: Electric field and current density throughout the head, as well as direct neural activation within the brain, were computed using the finite element method. Regions representing passive volume conductors (skin, skull, cerebrospinal fluid) were extracellularly coupled to an excitable neural continuum region representing the brain. The skull was modeled with anistropic electrical conductivity., Results: Simulation results indicated that direct activation of the brain occurred immediately beneath the electrodes on the scalp, consistent with existing imaging studies. In addition, we found that the brainstem was also activated using a right unilateral electrode configuration. Simulation also demonstrated that a reduction in stimulus amplitude or pulse width led to a reduction in the spatial extent of brain activation., Conclusions: The novel model described in this study was able to simulate direct excitation of the brain during ECT, was useful in characterizing differences in neuronal activation as electrode placement, pulse width, and amplitude were altered, and is proposed as a tool for further exploring the effects of variations in ECT stimulation approaches. Results from the simulations assist in understanding recently described clinical phenomena, in particular, the reduction in cognitive side effects with ultrabrief pulse width stimulation, and greater effects of the ECT stimulus on cardiovascular function with unilateral electrode placement., (Crown Copyright © 2012. Published by Elsevier Inc. All rights reserved.)

Objectives: This study aimed to describe the practice of an unmodified electroconvulsive therapy (ECT) in a typical urban hospital setting in Pakistan., Methods: This is a retrospective naturalistic study of patients who received ECT at Rawalpindi General Hospital between June 2000 and June 2008 by chart review. All useful data that could be retrieved from the charts were recorded., Results: The process of administering ECT at the hospital is described. During the study period, of a total of 5240 patients who were admitted to the hospital, 1520 (29%) were administered ECT. Of these, 1352 (88.9%) did not get any kind of anesthesia during the procedure. The mean age of patients was 34.89 years, and the leading diagnoses were depression (60.8%), bipolar disorder (17.8%), and schizophrenia (9.1%). The mean number of ECTs received for these diagnoses were 5.78, 5.52, and 6.34, respectively. A total of 249 (16.7%) patients discontinued ECT against medical advice., Conclusions: In countries with limited resources, ECT is practiced in a markedly different way from more developed countries; although administering ECT without anesthesia is not desirable, in the face of severe economic constraints, it is often necessary.

Objectives: Bispectral index (BIS) value measures the level of hypnosis (sedation) during anesthesia. It uses electroencephalographic signals to measure the level of sedation. Electroconvulsive therapy (ECT)-induced changes in electroencephalography last for several hours to days. How this affects BIS values is unknown., Methods: In 30 patients with schizophrenia or mood disorders who were prescribed ECT (bitemporal, brief-pulse ECT), BIS values were obtained before the start of anesthesia on the first (baseline), fourth (48 hours after the third ECT), and seventh ECT (48 hours after the sixth ECT) sessions. Bispectral index values were recorded in resting state and during a short conversation a few minutes before the induction of anesthesia. The changes in BIS values through the course of ECT were analyzed using repeated-measures analysis of variance and the McNemar test., Results: Mean (SD) resting BIS value dropped from 91.6 (6.6) at baseline to 79.7 (20.2) after the sixth ECT (repeated-measures analysis of variance occasion effect: F = 6.78; df = 2,58; P = 0.02). The drop in corresponding values during conversation was not significant. The proportion of patients whose resting BIS values were in the sedated/anesthetized range increased from 26% at baseline to 60% after the sixth ECT session (McNemar test: P = 0.031)., Conclusions: Bispectral index values of awake individuals in resting state drop significantly through a course of bitemporal brief-pulse ECT. Anesthesiologists should be aware that a considerable proportion of patients who have received a course of ECT may have BIS values in the sedated/anesthetized range even when they are awake. The BIS may not provide accurate estimation of the depth of anesthesia during ECT after the initial ECT sessions.

Electroconvulsive therapy (ECT) has been used clinically since 1938. Its most common use is in the treatment of depression: first line treatment where rapid recovery is a priority, but more frequently as an effective treatment for patients who do not respond to pharmacological and psychological approaches. Whilst it is widely hailed as an effective treatment, concerns about its effect on cognition remain. The development of magnetic seizure therapy (MST) over the past decade has attempted to devise a therapy with comparable efficacy to ECT, but without the associated cognitive side effects. The rationale for this is that MST uses magnetic fields to induce seizures in the cortex, without electrical stimulation of brain structures involved with memory. MST has been used successfully in the treatment of depression, yet there is a dearth of literature in comparison with ECT. We present a systematic review of the literature on ECT (from 2009-2011) and MST (from 2001-2011).

To clarify advantages of unilateral electrode placement as an optimisation technique for electroconvulsive therapy (ECT) for depression, aims were to meta-analyse unilateral ECT effects on cognitive performance relative to: (1) bitemporal electrode placement, (2) electrical dosage, and (3) time interval between final treatment and cognitive reassessment. Relevant electronic databases were systematically searched through May 2009, using the terms: "electroconvulsive therapy" and ["cogniti∗", "neuropsycholog∗", "memory", "attention", "executive", "spatial", or "intellectual"]. Inclusion criteria were: independent study of depressed patients receiving unilateral or bitemporal brief-pulse ECT; within-subjects design; use of objective cognitive assessments; available mean electrical dosage for unilateral samples. Standardized pre-post ECT weighted effect sizes were computed and pooled within 16 cognitive domains by a mixed-effects model. Thirty-nine studies (1415 patients) were meta-analysed. Up to three days after final treatment, unilateral ECT was associated with significantly smaller decreases in global cognition, delayed verbal memory retrieval, and autobiographical memory, compared to bitemporal ECT. Significant publication bias was found for autobiographical memory, favouring reporting of larger percentage loss. Higher unilateral ECT electrical dosage predicted larger decreases in verbal learning, delayed verbal memory retrieval, visual recognition, and semantic memory retrieval. When retested more than three days after completing ECT, no significant differences remained between the two electrode placements; for unilateral ECT, electrical dosage no longer predicted cognitive performance whereas increasing interval between final treatment and retesting predicted growing improvement in some variables. This interval is a more useful long-term predictor of cognitive function than electrode placement or electrical dosage following unilateral ECT., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Here, we report the case of a patient successfully treated by a series of electroconvulsive therapy (ECT) who had implanted skull fixation devices made of titanium alloy. The patient was a 57-year-old man with bipolar I disorder. He was hospitalized for the treatment of manic symptoms of bipolar I disorder with pharmacotherapy and ECT. He sustained a fall and hit his head hard on the ground. Acute subdural hematoma developed, and emergent surgery to remove the hematoma was carried out. Cranioplasty was performed using fixation devices made of titanium alloy (Ti 6Al-4V). In order to control his manic symptoms, a series of ECT was readministered from 1 week after surgery. No adverse effects occurred. Devices must be investigated and chosen very carefully for permanent implantation, especially in patients during a course of ECT.

Electroconvulsive therapy (ECT) is the most effective treatment for severe depressive disorder, and yet the mechanisms of its therapeutic effects remain largely unknown. A novel computational model is presented in this study to simulate and investigate direct cortical excitation caused by bitemporal electroconvulsive therapy (BT ECT), using a finite element model (FEM) of the human head. The skull was modeled with anisotropic conductivity, with an excitable ionic neural model incorporated into the brain based on the classic Hodgkin-Huxley formulation. Results suggested that this model is able to reproduce direct stimulation of the cortex during the application of ECT.

Right unilateral ultra-brief electroconvulsive therapy (RUL UB ECT) has been shown to be efficacious with minimal cognitive adverse effects in adult patients with major depression. We present the case of a 14-year-old girl with major depressive disorder with catatonic and psychotic features whose symptoms remitted after 12 treatments of RUL UB ECT., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

April 1938. The patient with the shaved head is passively lying on a bed on the first floor of a room-laboratory of the Clinic of Nervous and Mental Diseases of the Royal University of Rome. Several electric shocks are administered under strict supervision of the medical team of Ugo Cerletti (1867-1963). After the treatment, his psychic conditions get somewhat better. The electroshock machine, whose prototype is preserved at the Museum of the History of Medicine of the Sapienza University of Rome, together with manuals, patents and scientific and historical documentation, was invented and patented by Lucio Bini (1908-1964), a pupil of Cerletti. The use of electroshock replaces both the insulin therapy and the first attempts at a chemical treatment of psychic disorders. Until the 1950s no alternative treatments were available. Electroconvulsive therapies divided the public opinion and the scientific community. This controversial history is reflected in the eyes of the visitors to the Museum. When looking at the Bini-Cerletti machine they seem to ask: how did the patient feel? Was it fair to resort to such an practice so invasive, and lacking a definite scientific experimentation?

Objective: To investigate contemporary Dutch practice of electroconvulsive therapy (ECT) and adherence to national and international ECT guidelines., Methods: Among psychiatrists from all Dutch ECT sites in university and general hospitals (n = 24) and psychiatric hospitals (n = 11), a survey was conducted regarding (1) characteristics of practitioners and institutions, (2) clinical practice of ECT, and (3) technical aspects of ECT. Adherence to 16 criteria selected from (inter)national guidelines was scored., Results: Response rate was 94% (all 24 university and general hospitals and 9 of 11 psychiatric hospitals). Most respondents had extensive experience with ECT (median, 10 years; interquartile range, 4-15 years). Annually, approximately 8.5 sessions of ECT per 10,000 inhabitants were administered. In all ECT sites, 24% used exclusively bilateral electrode placement, 26% used ultrabrief pulse width, and 36% used dosage titration methods. Many practitioners had no knowledge of pulse width (42%) or of current characteristics (12%). Of the 16 investigated criteria, 14 were followed in at least 75% of the institutions., Conclusions: Although still increasing, the use of ECT in the Netherlands remains modest. Electroconvulsive therapy is generally practiced according to (inter)national guidelines. Electroconvulsive therapy is mostly started unilaterally, and generally, age-dependent dosage methods are being used. Knowledge on pulse width and current characteristics is limited. The implementation of updated guidelines might offer the opportunity to further improve practice and stimulate availability of ECT.