ABSTRACT
Background:
There is a lack of data on the use of continuation electroconvulsive therapy (C-ECT) from India.
Objectives:
This study aimed to evaluate the clinical profile and outcome of patients receiving C-ECT.
Materials and Methods:
The ECT register was used to identify patients receiving C-ECT (ECT after completion of an acute course, to maintain remission or prevent relapse) from 2011 to July 2022. Socio-demographic, clinical, and treatment outcome details were extracted from their treatment records.
Results:
A total of 72 C-ECT courses were identified that were used in 60 patients. Out of all the patients receiving ECT, only 3.25% of patients receive C-ECT. The majority of the patients were male (60%). The mean age of the patients at the time of starting ECT was around 39 years. The most common diagnosis was schizophrenia (73.3%), followed by recurrent depressive disorder (21.6%). The most common indication was persistent psychotic symptoms poorly responding to multiple antipsychotic trials of 3.09 (SD: 1.39), including clozapine. These patients received a mean of 22.58 (SD: 8.05; range: 10 to 46) ECTs, with 10.0 (SD: 4.83) ECTs for the management of the acute phase of illness and 12.57 (SD: 6.20) ECTs as part of continuation treatment. The majority (61.1%) of the patients received four (once weekly) C-ECTs in the first month, followed by three more in the next month. However, 16 patients received weekly ECTs during the second month too, as symptoms worsened with the lowering of frequencies. Twelve patients received more than one C-ECT course. The majority of the patients maintained the improvement gained during the acute phase or showed further improvement with C-ECT along with ongoing pharmacotherapy as rated on appropriate scales. The Clinical Global Impressions-Severity (CGI-S) difference before and after C-ECTs was 2.94 (SD: 0.88).
Conclusions:
C-ECT is considered in only in a small proportion of patients. However, when used, it is effective in maintaining the benefits gained during the acute course of ECT and preventing relapse.
Keywords: Continuation, ECT, outcome
INTRODUCTION
Electroconvulsive therapy (ECT) has been shown to be beneficial in the management of many psychiatric disorders. However, a successful course of acute ECT is inevitably followed by relapse rates of more than 50%,[1] especially in the initial 6 months after the ECT course.[2] To overcome this, many authors have suggested using ECT for prevention of relapse, although at a lower frequency, after the acute phase of treatment with ECT.[3,4]
Continuation electroconvulsive therapy (C-ECT) refers to ECT delivered after the acute course for initial six months, and when ECT is continued beyond 6 months of the acute course to prevent relapse, it is considered maintenance ECT (M-ECT).[5] However, the terms C-ECT and M-ECT are at times used interchangeably.[1]
Research on C-ECT and M-ECT has shown that these are safe and effective means of treatment for patients with psychotic or affective illness, who are prone to relapses.[6] However, data in general suggest that these are used less frequently and over the years their use has declined, especially in developed country settings. A survey of psychiatrists from the United States and the United Kingdom during the earlier years suggested that 25–60% of the psychiatrists used C/M-ECT.[7,8] However, a recent survey of ECT clinics in the United Kingdom suggested that only 14 patients received C-ECT during 1996 to 1997, which increased to 38 patients during 2001 to 2002. However, this reduced to 26 patients during 2006 to 2007.[9]
In terms of common diagnostic indications for ECT, these vary from country to country. Data from countries such as Australia, New Zealand, the United States, and many European countries suggest that affective disorders form the most common diagnostic group, whereas data from African countries, Asian countries, and Brazil suggest that schizophrenia/schizoaffective disorders form the most common diagnostic category.[10] However, in terms of the use of C/M-ECT, limited data are available for the diagnostic groups. Data from the United Kingdom suggest that patients with affective disorders are more common among those receiving C/M-ECT.[9]
A review of the literature suggests that in psychotic patients, treatment-resistant psychotic symptoms and relapse of psychotic symptoms despite being on adequate treatment are the most common indications for C-ECT/M-ECT.[11]
In terms of usefulness, available information for psychotic patients suggests that multiple domains such as positive and negative symptoms, suicidal behavior, and aggression respond to C/M-ECT with overall improvement in functional status.[11] With regard to affective illness, a recent meta-analysis reported the presence of limited data that suggest that C/M-ECT when combined with pharmacotherapy reduces relapse and recurrence till 1 year when compared to only pharmacotherapy.[12]
Most of the available data on C/M-ECT on affective disorders and psychotic disorders are from developed countries with limited data from developing countries. A survey of data from Asian countries documented the use of C/M-ECT in these countries mainly for major depression and schizophrenia.[13]
A previous survey involving ECT services of 74 institutes from India suggested that in 29 institutes, C-ECT was used. This survey also showed that acute phase ECT is most commonly used in India for patients with schizophrenia; however, C/M-ECT was most commonly used for patients with depression.[14] According to this survey, M-ECT was used in 17 of 74 institutes. The majority of the courses of M-ECT were used for patients with schizophrenia, followed by those with depression.[14] In terms of efficacy data from India, a recent open-labeled study from India that compared the outcome of treatment-resistant schizophrenia (TRS) patients who received acute course ECT followed by C-ECT and those receiving clozapine only showed that patients receiving C-ECT showed better improvement in the psychopathology.[15] However, there is a lack of data from India in terms of frequency of use of C/M-ECT, common indications for the same, and the usefulness of C/M-ECT.[16] In this background, this study aimed to evaluate the socio-demographic and clinical profile, course, and outcome parameters of patients receiving C-ECT.
MATERIALS AND METHODS
This retrospective study was conducted in a tertiary care institute in North India. The study was approved by the Ethics Committee of the institute (INT/IEC/2021/SPL-1218; dated: September 14, 2021).
At our center, bilateral modified ECT is provided three times a week. Once ECT is considered for a patient by the treating team headed by a consultant psychiatrist, the patient and/or their caregivers (usually a family member) are approached and explained about the procedure. Those providing written informed consent are evaluated further for fitness to undergo ECT. The pre-ECT evaluation includes undergoing a detailed physical examination, mental status examination, investigations, and a preanesthetic evaluation. Pre-ECT investigations include complete blood count, renal function test, liver function test, serum electrolyte levels, fasting blood sugar, chest radiography, and electrocardiography. Additional investigations are done as warranted by the clinical history and physical examination findings. Patients then undergo preanesthetic evaluation. Patients found suitable for ECT are rated on standard rating scales, depending on the underlying condition, such as Positive and Negative Syndrome Scale (PANSS)[17] for psychotic illness, Bush Francis Catatonia Rating Scale (BFCRS)[18] for catatonia, Hamilton Depression Rating Scale (HDRS)[19] for depressive illness, and Young Mania Rating Scale (YMRS)[20] for mania.
A course of ECT involves the administration of 6–10 ECT treatments in most cases with occasional patients receiving a higher or lower number of ECT treatment. Once the response to ECT plateaus over two consecutive ECTs, the ECT is stopped and the patients are monitored for symptoms. During the ECT course, psychotropics are continued as per the requirement. Only a small proportion of the patients are considered for C-ECT. Patients who usually respond to ECT after the initial course of ECT and later experience a relapse of symptoms that are not managed by adequate pharmacological treatment are considered for the second course of ECT, and depending on the availability of alternative pharmacological treatment, patients are considered for C-ECT to maintain remission and prevent relapse. In some patients who have a history of frequent relapse of symptoms, C-ECT is considered after the first ECT course itself if there are no or limited pharmacological options to prevent relapse of symptoms.
The decision to consider C-ECT depends on the treating team headed by a consultant psychiatrist. At our center, for the C-ECT, usually during the first 1 month four weekly ECTs are administered, and this is followed by two ECTs in the second month at fortnightly intervals. After the second month, patients receive once-a-month ECT. However, as most of the C-ECTs are given on an outpatient basis, a strict regimen is often not followed, because at times patients miss the date for the ECT and the same has to be rescheduled. In occasional cases, if fortnightly ECTs during the second month lead to a relapse of symptoms then the frequency of ECT is increased to 3–4 times a month, depending on the need for adequate symptom control.
Data of all of the patients receiving ECT are entered into an ECT register, and it is checked from time to time for completion. Data of the ECT register are also entered into a Statistical Package for the Social Sciences (SPSS) file and updated from time to time.
For this study, the ECT register was used to identify patients receiving C-ECT from 2011 to July 2022. The socio-demographic, clinical, and treatment outcome details were extracted from their treatment records and analyzed. Based on the available data from the treatment records, the clinical status of the patients was retrospectively rated on Clinical Global Impression-Severity (CGI-S) scale[21] at the end of C-ECT (i.e., after 6 months of C-ECT). Data for other scales were obtained from the treatment records.
Data were analyzed using SPSS, Fourteenth Version (SPSS version 14). Mean and standard deviation were computed for the continuous variables, and frequency and percentages were calculated for the categorical variables.
RESULTS
From 2011 to July 2022, 72 C-ECT courses were identified that were used in 60 patients. Eight patients received two courses of C-ECT, and two patients, three courses of C-ECT.
Number of ECT and C-ECT
Over the years, the number of patients receiving ECT increased from 87 patients in 2011 to 310 in 2019. However, in 2020 and 2021 there was a reduction in the patients receiving ECT, due to the coronavirus disease 2019 (COVID-19) pandemic. In terms of the proportion of patients receiving C-ECTs per year, it ranged from 0.46% to a maximum of 6.06%. Overall, out of all the patients receiving ECT, only 3.25% of patients receive C-ECT [Table 1].
Table 1.
Number of patients receiving ECTs and C-ECTs
| Year | Number of patients started on ECT | Number of patients started on C-ECT |
|---|---|---|
| 2011 | 87 | 1 (1.5%) |
| 2012 | 83 | 3 (3.6%) |
| 2013 | 108 | 2 (1.85%) |
| 2014 | 133 | 2 (1.5%) |
| 2015 | 202 | 8 (3.96%) |
| 2016 | 207 | 5 (2.43%) |
| 2017 | 245 | 11 (4.48%) |
| 2018 | 282 | 17 (6.02%) |
| 2019 | 310 | 5 (1.61%) |
| 2020 | 143 | 2 (1.39%) |
| 2021 | 198 | 12 (6.06%) |
| Up to July 2022 | 213 | 1 (0.46%) |
Demographic data of patients receiving C-ECT
Of 60 patients receiving C-ECT courses, 44 patients were diagnosed with schizophrenia/schizoaffective disorders and 16 were patients with affective disorders. Among the 16 patients with affective disorder, one was diagnosed with major depressive disorder, 13 were diagnosed with recurrent depressive disorder, with the current episode being severe depression, and two were diagnosed with bipolar affective disorder, with the current episode being that of depressive polarity.
Most of the patients were male (60%). The mean age of starting ECT was 39 years (SD: 14.99) with those aged 60 or more forming one-fifth (18.3%) of the total number of patients receiving C-ECT. When those with psychotic and affective disorders were compared, no statistically significant difference was noted between the two groups, except that the age of onset of patients with affective disorders and the proportion of elderly patients with affective disorders were significantly higher than those with psychotic disorders [Table 2].
Table 2.
Demographic profile of patients receiving C-ECT
| Variables | Whole group n (%)/mean (SD) [range] n=60 | Psychotic group n (%)/mean (SD) n=44 | Affective group n (%)/mean (SD) n=16 | Chi-square value/t (P) |
|---|---|---|---|---|
| Gender | ||||
| Male | 36 (60.0) | 28 (63.6) | 8 (50.0) | 0.909 (0.383) |
| Female | 24 (40.0) | 16 (36.4) | 8 (50.0) | |
| Age of onset of ECT (years) | 39.35 (14.99) [18-73] | 32.41 (8.52) | 58.44 (12.08) | -9.319 (<0.001)*** |
| Age ≥60 years | 11 (18.3) | 1 (2.3) | 10 (62.5) | 28.426 (<0.001)*** |
***P<0.001
Clinical features
About two-thirds of the patients considered for C-ECT had received at least one course of ECT (for management of acute phase) in the past (before the acute course which was followed by C-ECT), and the majority of them had satisfactory response to ECT in the past. The mean duration of episode/current worsening before consideration of a course of ECT followed by C-ECT was 18.17 (SD: 28.9) months. Patients with schizophrenia had received a mean of 3.09 (SD: 1.39) antipsychotic trials before being considered for C-ECT, and patients with affective disorders had received a mean of 1.44 (SD: 1.04) antidepressant trials before consideration of C-ECT. The majority (88.6%) of patients with schizophrenia/schizoaffective disorder had received an adequate trial of clozapine before consideration of C-ECT. More than half (53.3%) of patients had psychiatric comorbidity, with the affective group having significantly more comorbidities [Table 3].
Table 3.
ECT parameters and course
| Variables | Whole group Number n (%)/mean (SD) [range] n=60 | Psychotic group Number n (%)/mean (SD) n=44 | Affective group Number n (%)/mean (SD) n=16 | Chi-square value/t (P) |
|---|---|---|---|---|
| History of ECT in the past | 36 (60.0) | 25 (56.8) | 11 (68.8) | 0.696 (0.404) |
| Satisfactory response to ECT in the past (among those who received ECT) | 33/36 (91.67) | 22/25 (88.00) | 11/11 (100) | FE=0.761 |
| Duration of worsening before ECT initiation (in months) | 18.17 (28.90) [0.5-108] | 20.46 (30.51) | 12.61 (24.70) | Z=0.546 |
| Number of psychotropic trials before starting ECT | - | 3.09 (1.39) | 1.44 (1.04) | - |
| [1-6] AP | [1-3] AD | |||
| Median: 30 | Median: 1.5 | |||
| Clozapine trial | - | 39 (88.6) | - | - |
| Psychiatric comorbidity—present | 32 (53.33) | 20 (45.5) | 12 (75) | Y=3.01 (0.08) |
| Affective symptoms/disorder | 11 (18.33) | 11 (26.2) | - | - |
| Anxiety symptoms/disorder | 15 (25) | 4 (9.1) | 11 (68.8) | FE=(0.001)*** |
| Obsessive–compulsive symptoms/disorder | 9 (15) | 9 (20.5) | 0 (0) | Y=1.949 (0.096) |
| Personality traits/disorder | 1 (1.7) | 0 (0) | 1 (6.3) | FE=0.236 |
| Substance dependence—present | 13 (21.7) | 10 (22.7) | 3 (18.8) | Y=0.000 (1.000) |
| Alcohol dependence | 4 (6.7) | 3 (6.8) | 1 (6.3) | FE=0.695 |
| Opioid dependence | 2 (3.3) | 1 (2.3) | 1 (6.3) | FE=441 |
| Benzodiazepine dependence | 1 (1.7) | 1 (2.3) | 0 (0) | FE=0.764 |
| Tobacco dependence | 6 (10) | 5 (11.4) | 1 (6.3) | Y=.054 (0.816) |
| Polysubstance dependence | 1 (1.7) | 1 (2.3) | 0 (0) | FE=0.764 |
| Medical comorbidity—present | 15 (25) | 9 (20.5) | 6 (37.5) | 3.060 (0.08) |
| Diabetes mellitus | 4 (6.7) | 2 (4.5) | 2 (12.5) | FE=0.234 |
| Hypertension | 6 (10) | 3 (6.8) | 3 (18.8) | FE=0.136 |
| Thyroid dysfunction | 7 (11.7) | 3 (6.8) | 4 (25.0) | FE=0.046* |
| Epilepsy | 2 (3.3) | 2 (4.5) | 0 (0) | FE=0.58 |
***P≤0.001; *P<0.05; FE= Fischer exact value; Y= Chi-square value with Yate’s correction; Z: Mann Whitney Z Value. Psychiatric comorbidity, Substance dependence and Medical comorbidity- some of the patients had more than one comorbidity
In terms of psychopathology before consideration of the current course of ECT and C-ECT, the majority of the patients with schizophrenia/schizoaffective disorder had poor insight (86.8%), presence of sleep disturbance (75.5%), persistent positive symptoms (67.9%), presence of disorganized behavior (54.7%), persistent negative symptoms (41.5%), presence of agitation/violence (41.5%), delusions against family members (32.1%), catatonic symptoms (17%), and history of self-harm (13.2%). More than half (56.6%) of the patients with schizophrenia/schizoaffective disorder had a history of recurrent hospitalization.
More than half of the patients with affective disorder had treatment-resistant depression (56.3%, n = 9) before starting the current course of ECT and C-ECT. In terms of the symptoms in the current episode, psychotic depression was seen in 12.5% (n = 2), and catatonia was seen in 18.8% (n = 3).
In all the patients, C-ECT was considered because of poor response to adequate doses of appropriate psychotropics, despite taking these with good adherence or frequent relapses despite taking adequate doses of appropriate psychotropics, with good adherence.
ECT parameters and ECT course variables
Most of the patients were started on ECT as inpatients (62.5%), with a significantly higher proportion of those with schizophrenia/schizoaffective disorder being started on ECT as inpatients, compared with those with affective disorders. The total number of ECTs received ranged from 10 to 46, with a mean of 22 ECTs (SD: 8.05), a mean of 10 ECTs administered during the acute course, and 12.57 (SD: 6.2) C-ECT over 6-month period [Table 4]. In terms of the frequency of ECTs during the continuation phase, the majority of the patients received ECTs at the predetermined frequency. However, a small proportion of the patients required an increase in the frequency of C-ECTs during the subsequent months. In some of the patients, C-ECTs could be stopped due to the sustained improvement in symptoms. In 25 (41.66%) patients (18 in the psychotic group and seven in the affective group), C-ECT was continued beyond 6 months as M-ECT [Table 4].
Table 4.
ECT details related to the C-ECT course
| Variables | Whole group Number (frequency)/mean (SD) [range] n=72 (number of ECT courses) | Psychotic group Number (frequency)/mean (SD) n=53 (number of ECT courses) | Affective group Number (frequency)/mean (SD) n=19 (number of ECT courses) | Chi-square value/t (P) |
|---|---|---|---|---|
| Setting of ECT | ||||
| Inpatient | 45 (62.5) | 37 (69.8) | 8 (42.1) | 4.581 (0.032)* |
| Outpatient | 27 (37.5) | 16 (30.2) | 11 (57.9) | |
| Total number of ECTs | 22.58 (8.05) [10-46] | 23.58 (8.62) | 19.79 (5.46) | 1.790 (0.078) |
| Total number of acute ECTs | 10.00 (4.83) [4-30] | 10.58 (5.12) | 8.37 (3.58) | 1.741 (0.086) |
| Median: 9.00 | Median: 9.00 | Median: 8.00 | ||
| Total number of C-ECTs | 12.57 (6.20) [6-30] | 13.00 (6.99) | 11.37 (4.50) | 0.983 (0.329) |
| Median: 12.00 | Median: 12.00 | Median: 12.00 | ||
| Number of C-ECTs | ||||
| In the first month | 3.47 (0.77) [1-4] | 3.49 (0.78) | 3.42 (0.77) | 0.336 (0.738) |
| In the second month | 2.68 (0.95) [1-4] | 2.79 (0.99) | 2.37 (0.76) | 1.697 (0.094) |
| In the third month | 1.88 (1.11) [0-4] | 2.04 (1.11) | 1.47 (1.01) | 1.941 (0.056) |
| In the fourth month | 1.42 (1.11) [0-4] | 1.49 (1.19) | 1.21 (0.85) | 0.943 (0.349) |
| In the fifth month | 1.04 (1.04) [0-4] | 1.06 (1.13) | 1.00 (0.75) | Z=0.788 |
| In the sixth month | 0.72 (0.89) [0-4] | 0.78 (0.97) | 0.58 (0.61) | Z=0.726 |
| Course of C-ECTs: In the first month | ||||
| Weekly | 44 (61.1) | 34 (64.2) | 10 (52.6) | - |
| Every 10th day | 20 (27.8) | 12 (22.6) | 8 (42.1) | |
| Every 2 weekly | 6 (8.3) | 6 (11.3) | 0 (0) | |
| Monthly | 2 (2.8) | 1 (1.9) | 1 (5.3) | |
| In the second month | ||||
| Weekly | 16 (22.2) | 16 (30.2) | 0 (0) | - |
| Every 10th day | 25 (34.7) | 15 (28.3) | 10 (52.6) | |
| Every 2 weekly | 23 (31.9) | 17 (32.1) | 6 (31.6) | |
| Monthly | 8 (11.1) | 5 (9.4) | 3 (15.8) | |
| In the third month | ||||
| Weekly | 7 (9.7) | 7 (13.2) | 0 (0) | - |
| Every 10th day | 11 (15.3) | 8 (15.1) | 3 (15.8) | |
| Every 2 weekly | 29 (40.3) | 22 (41.5) | 7 (36.8) | |
| Monthly | 17 (23.6) | 12 (22.6) | 5 (26.3) | |
| No ECT | 8 (11.1) | 4 (7.5) | 4 (21.1) | |
| In the fourth month | ||||
| Weekly | 5 (6.9) | 5 (9.4) | 0 (0) | - |
| Every 10th day | 3 (4.2) | 3 (5.7) | 0 (0) | |
| Every 2 weekly | 26 (36.1) | 17 (32.1) | 9 (47.4) | |
| Monthly | 21 (29.2) | 16 (30.2) | 5 (26.3) | |
| No ECT | 17 (23.6) | 12 (22.6) | 5 (26.3) | |
| In the fifth month | ||||
| Weekly | 2 (2.8) | 2 (3.8) | 0 (0) | - |
| Every 10th day | 4 (5.6) | 4 (7.5) | 0 (0) | |
| Every 2 weekly | 16 (22.2) | 11 (20.8) | 5 (26.3) | |
| Monthly | 23 (31.9) | 14 (26.4) | 9 (47.4) | |
| No ECT | 27 (37.5) | 22 (41.5) | 5 (26.3) | |
| In the sixth month | ||||
| Weekly | 1 (1.4) | 1 (1.9) | 0 (0) | - |
| Every 10th day | 3 (4.2) | 3 (5.7) | 0 (0) | |
| Every 2 weekly | 6 (8.3) | 5 (9.4) | 1 (5.3) | |
| Monthly | 27 (37.5) | 18 (34.0) | 9 (47.4) | |
| No ECT | 35 (48.6) | 26 (49.1) | 9 (47.4) | |
| Beyond 6 months (those receiving M-ECT) | 25 (34.7) | 18 (34.0) | 7 (36.8) | 0.051 (0.821) |
*P<0.05; MW- Mann Whitney Z value
Outcome of C-ECT
In terms of improvement in psychopathology, the CGI-S decreased from 6.6 (SD: 0.62) at the time of starting ECT (acute phase ECT) to 3.63 (SD: 0.79) at the end of C-ECT. A similar reduction was noted in other rating scales [Table 5]. Most of the patients underwent a further change in psychotropics (i.e., no change in the medications per se, but not necessarily a change in the doses of ongoing psychotropics) during C-ECT. The majority (n = 44) of the psychotic patients have been maintaining well on the ongoing antipsychotics after stopping of C-ECT or while receiving M-ECT, with nine patients requiring change or addition of another antipsychotic and restarting acute ECT course followed by C-ECT. Among the nine patients in the psychotic group who relapsed after C-ECT course, five of them relapsed within one year of stopping C-ECT, while the other remained well up to one year of stopping C-ECT before relapsing.
Table 5.
C-ECT outcome details
| Rating scale | Baseline score before starting acute course of ECT Mean (SD) [range] | Final score at the end of C-ECT Mean (SD) [range] | t-test (P) |
|---|---|---|---|
| CGI-S score | 6.60 (0.62) [5-8] | 3.63 (0.79) [2-5] | 24.196 (0.001)*** |
| PANSS score | 98.11 (24.93) [48-154] | 55.10 (14.75) [25-78] | 10.166 (0.001)*** |
| BFCRS score | 22.14 (4.22) [12-28] | 4.14 (4.18) [0-12] | 13.381 (0.001)*** |
| HDRS score | 27.36 (6.23) [15-45] | 6.21 (2.42) [1-9] | 13.572 (0.001)*** |
***P≤0.001. HDRS=Hamilton Depression Rating Scale, BFCRS=Bush Francis Catatonia Rating Scale, PANSS=Positive and Negative Syndrome Scale
In terms of side effects, none of the patients reported significant cognitive impairment while receiving C/M-ECT.
DISCUSSION
The present study aimed to assess the profile of patients receiving C/M-ECT in a tertiary care hospital in a developing country setting. The present study shows that on a yearly basis only a small proportion of the patients receiving ECT go on to receive C-ECT. One of the previous studies from Australia reported that about one-fifth of the elderly depressed patients receiving acute ECT go on to receive C-ECT.[22] When we compare our findings with those of this study, it can be concluded that C-ECT is rarely used in patients with severe mental disorders in the Indian setting. A survey of different ECT clinics from United Kingdom reported that only 14 patients received C-ECT from 1996 to 1997, which increased to 38 from 2001 to 2002, but again reduced to 26 patients from 2006 to 2007. In this study too, the mean age of the patients was close to 60 years. However, the authors did not give the denominator in the form of a total number of patients undergoing ECT to determine the proportion of patients receiving ECT. However, it can be presumed that the number of patients receiving C/M-ECT would form a very small proportion of the total number of patients receiving ECT in the United Kingdom.[9] Accordingly, the findings of the present study are in consonance with this study in terms of the proportion of patients receiving C/M-ECT.
A survey of ECT services in India reported that of the 29 institutes in which C-ECT was used, in 20 institutes, only 1–10% of the patients receiving ECT went on to receive C-ECT.[14] Our findings of 0.46% to 6.06% per year support these figures.
In the present study, the mean age of the study sample was 39 years (SD: 14.99) years. This is in contrast to most of the studies from developed countries that have reported the use of C-ECT mostly for elderly patients.[9,22] This difference in the age group of patients receiving ECT among the developed countries and developing countries is supported by previous reviews/surveys, which suggest that compared with the developed countries, ECT is more often used in young patients in developing countries.[13,14,23] Accordingly, the findings of the present study are supported by the overall findings from developing countries but differ from those from developed countries. This difference could possibly be attributed to the fact that in developing countries like India, ECT is not considered one of the last treatment options and is often used much earlier. This possibly leads to young patients forming a large proportion of patients receiving ECT.
In the present study, the majority of the patients who received C-ECT were male, which is supported by previous studies from India that have reported the gender profile of patients receiving acute ECT course.[13,14,24,25] Previous studies from developed countries suggest that females form the predominant group of patients receiving C-ECT.[9,22] The gender distribution across the studies is possibly guided by the diagnostic group with studies having a higher proportion of patients with depression reporting higher use of C-ECT among females.[9]
In the present study, of the 60 patients receiving C-ECT courses, 44 patients were diagnosed with schizophrenia/schizoaffective disorders and 16 were diagnosed with depressive disorders. This finding is also in contrast to the findings from developed countries that suggest that C-ECT is mostly used for depressive disorders.[9] Furthermore, the findings are also not in line with the previous survey from India that reported C/M-ECT was most commonly used for patients with depression.[14] A higher proportion of our study sample being that of schizophrenia can be understood from the fact that in our setting, ECT is often used for augmentation for patients showing poor response to clozapine.[26] However, for patients with depression, ECT is often used before tricyclic antidepressants. Accordingly, patients who respond to the acute course of ECT are often managed with tricyclic antidepressants later on. Hence, this could possibly explain the lower use of C-ECT in patients with depression in our study.
In the absence of established guidelines, different treatment schedules are suggested for C-ECT. One of the methods that is utilized in determining the course of C-ECT includes the “tapering schedule” from weekly to monthly over time, “fixed schedule” with C-ECT every 1 to 4 weeks, or “as-needed schedule” in which 1–2 C-ECT is delivered when there are signs of relapse in the patient.[4] Another patient-focused regimen is Symptom-Titrated, Algorithm-Based Longitudinal ECT (STABLE) that could identify 100% of patients about 2 weeks before actual relapse, while exposing 20% of remitted patients to additional ECT.[27] A recent Clinical Practice Recommendations for Continuation and Maintenance of Electroconvulsive Therapy for Depression from Australia recommended that a flexible approach should be followed. As per this, there should be a space for adjustment of the frequency of ECT, and whenever the psychiatrist finds early signs of relapse or partial relapse, the frequency of ECT can be increased.[28] Some of the authors suggest that for schizophrenia, C-ECT was commonly administered weekly for the first month, biweekly for the next two months, and then monthly with variations depending on the clinical picture.[11]
When we look at the frequency of ECT in the present study, it is evident that despite attempting to follow the suggested recommendations (four C-ECT in the first month; two C-ECT in the second month, and one C-ECT monthly for the next 4 months), a flexible approach was used to decide about the number of ECTs in these patients and when required some of the patients received a fresh course of acute ECT. These findings suggest that future recommendations/guidelines for C-ECT should give flexibility to the clinicians to decide about the frequency of ECT based on symptom control.
Findings of the present study show that when used, C-ECT is associated with significant improvement in symptoms and low relapse rates, as indicated by the use of the second course of acute course of ECT in only 12 patients (i.e., 12 of 60 = 20%). These relapse rates are much lower than those reported for patients with depression in general and for patients with schizophrenia.[11]
In the present study, about one-third of the patients receiving C-ECT went on to receive M-ECT. The majority of the patients who received M-ECT were diagnosed with schizophrenia. These findings need to be understood in the background that the majority of our patients who received C-ECT were having TRS. It is quite possible that M-ECT was considered in view of the lack of good quality efficacy data to support the use of pharmacotherapy in patients with clozapine-resistant schizophrenia.[26]
The findings of the present study must be interpreted in light of its limitations. First, this was a retrospective study and the data were extracted from the treatment records. We did not extract information about the course of illness before consideration of C/M-ECT. The ratings of symptoms were not monitored after each ECT. The CGI rating was done retrospectively based on the information available in the treatment records in terms of symptomatic improvement as recorded during the routine follow-up. Future studies must attempt to overcome the limitations of the present study by following a prospective study design with a sample recruited across multiple centers. We did not extract the data for various ECT-related parameters.
To conclude, the present study suggests that C-ECT is used in a very small proportion (3.25%) of all the patients considered for ECT and only one-third of the patients receiving C-ECT go on to receive M-ECT. C/M-ECT is most often used for male patients, and it is most commonly used for the patient with schizophrenia, especially TRS. Most of the patients tolerate the C-ECT well and do not experience relapse while receiving the same. Accordingly, it can be said that C/M-ECT is effective and safe in the management of schizophrenia and depressive disorders.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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