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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 19-23

Indications and prescription pattern of electroconvulsive therapy: A 5-year retrospective medical record review of inpatients in a Tertiary Care Center


1 Consultant Psychiatrist, Serenity Clinic, Delhi, India
2 Department of Psychiatry, GSL Medical College, Rajahmundry, Andhra Pradesh, India
3 Registrar, Hunter New England Training in Psychiatry, New South Wales, Australia

Date of Submission12-Nov-2021
Date of Decision22-Dec-2021
Date of Acceptance29-Dec-2021
Date of Web Publication23-Jun-2022

Correspondence Address:
Dr. V. V. Jagadeesh Settem
Department of Psychiatry, GSL Medical College, Rajahmundry, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_267_21

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  Abstract 

Background and Aim: With the advent of pharmacological agents, there were many changes in prescription patterns for modified electroconvulsive therapy (MECT) over time across the globe. This study aims to evaluate the main indications and prescription patterns of MECT in a tertiary care center. Materials and Methods: A retrospective medical record review was done in a tertiary care hospital after the institutional ethics committee approval, accessing the MECT records of 310 patients who underwent the procedure during the 5-year study period using a semi-structured pro forma. Results: In our file review, we found that the most common diagnosis, for which MECT was prescribed, was schizophrenia 146 cases (47%), and the common indication was augmentation of therapy/to speed up the rate of improvement. Depressive disorder was the primary diagnosis in 81 (26%) cases followed by mania in 46 (15%) cases. Among the major symptomatology which led to the primary use of MECT, suicidality accounted for 72 (23.2%) cases and catatonia in 34 (11%) cases. The mean number of MECTs during the course was 6.4 (2.5) in bipolar disorder, and in schizophrenia, it was 6.3 (2.3). A response rate of 85% was observed. Patient acceptability of MECT was good as only seven (2.3%) patients withdrew consent after initiation of treatment. Conclusion: Most common diagnosis, for which MECT was prescribed, was schizophrenia followed by depression. MECT was most commonly used as an augmentation strategy; however, in case of depression, it was used as first line of management. Response rate to MECT and acceptability were good in majority.

Keywords: Acceptability, electroconvulsive therapy, indications, prescription patterns


How to cite this article:
Kota V S, Settem VV, Roy K. Indications and prescription pattern of electroconvulsive therapy: A 5-year retrospective medical record review of inpatients in a Tertiary Care Center. Arch Med Health Sci 2022;10:19-23

How to cite this URL:
Kota V S, Settem VV, Roy K. Indications and prescription pattern of electroconvulsive therapy: A 5-year retrospective medical record review of inpatients in a Tertiary Care Center. Arch Med Health Sci [serial online] 2022 [cited 2022 Oct 3];10:19-23. Available from: https://www.amhsjournal.org/text.asp?2022/10/1/19/347961


  Introduction Top


Electroconvulsive therapy (ECT), a mode of biological treatment which had its origins and application even before the development of antipsychotics, had endured a lot of changes till date. The idea of convulsive therapies stemmed from biological antagonism. Initially, chemical agents like camphor later on pentylenetetrazol (Metrazol) were used by Meduna.[1] Ugo Cerletti and Lucio Bini had devised a successful method using electrical current for inducing seizures as an alternative to Metrazol.[2] By 1940, ECT was widely used and in the ensuing decades, it became established as the principal method of clinical seizure induction.

A survey of practice of ECT in India showed that, after schizophrenia, major depression and mania are the most common indications for ECT,[3], and a similar trend has also been reported for Asian countries.[4],[5] According to standard recommended guidelines, ECT is used only to achieve rapid and short-term improvement of severe symptoms, after an adequate trail of other treatment options have been found to be ineffective and/or when the condition is found to be potentially life threatening, like in individuals with catatonia, prolonged or severe manic episode, and for acute treatment of severe depression.[6] The current state of the evidence does not allow the general use of ECT in the management of schizophrenia and depression.[6]

Initial experiments on efficacy of convulsive therapy were in schizophrenia patients, but with time, experience with ECT, and advent of pharmacological agents, there were changes in indications for ECT. Interestingly, it was found that recommendations varied in different parts of the world. Depression appears to be the most common diagnosis world over, whereas in India, schizophrenia is the most common diagnosis, for which ECT is prescribed.[5] At this juncture, it would be worthwhile to investigate the major indications, prescription patterns, symptoms profile, and average number of ECT sessions required for improvement across various diagnoses. This study aims to evaluate the main indications and prescription patterns of modified ECT (MECT) in the tertiary care center. It also looked into various reasons for the termination of ECT among different diagnoses.


  Materials and Methods Top


Study design and sample

This is a retrospective medical record review done in an inpatient setup in the department of psychiatry at a tertiary hospital, in Southern Karnataka. This hospital generally has patients visiting not only from Karnataka but also from adjacent areas bordering Kerala and Andhra Pradesh. After the Institutional Ethics Committee approval was taken, the MECT records from January 1, 2008 to December 31, 2013, i.e., 5-year time period were assessed from the inpatient medical records. All inpatients who underwent MECT, at our institute during the study period between the age group of 18 and 65 were included in the study. The sample recruited was the sequence of consecutive patients who underwent the procedure during the study period. The sample size is 310. Informed consent was taken from the patients and family members for the procedure. The patients who had (a) comorbid idiopathic seizure disorder, (b) other major physical illnesses such as coronary artery disease, cardiovascular disease, and uncontrolled hypertension, (c) who had any metallic prosthesis, and (d) who were not approved in the preanesthetic checkup were excluded from the study.

Study procedure

A semi-structured pro forma specifically designed for this study was used. The pro forma included sociodemographic data, psychiatric diagnosis as per ICD 10, duration of illness, psychopathology, past history of MECT, indication for MECT, number of sessions of MECT administered, reason for termination of treatment, and post-MECT complications. Data were reviewed from MECT charts of the inpatients medical records after cross-checking with the MECT register at the inpatient ward where all the procedural details of each session are regularly documented. The data in the MECT charts and the MECT ward register at the institute are regularly supervised by the treating team for each patient during the discharge and the grand rounds as a routine treatment protocol. The data reviewed from the charts were kept confidential.

Study variables

This study primarily evaluated the main indications and prescription pattern of MECT in the tertiary care center. The study also assessed various diagnosis for which MECT was prescribed, indications, number of MECTs required, reasons for termination among the different diagnoses.

Statistical analysis

All statistical analyses were done using the Statistical Package for the Social Sciences Version 19.0, IBM, Armonk, NY, United States. Categorical values were presented as frequency values and continuous variables using mean ± standard deviation. P value was calculated using ANOVA test comparing means and P < 0.05 was considered as significant.


  Results Top


Out of the study sample, 161 cases (52%) were male and 149 cases (48%) were female [Table 1]. Around 35 cases (11%) had comorbid substance dependence. Around seven cases (2.3%) had dull-normal intelligence [Table 1]. Less than 1% (n = 3) had comorbid personality disorder. All the other comorbidities such as fibromyalgia, drug-induced extrapyramidal symptoms, dysthymia, pathological gambling, pervasive developmental disorders, persistent somatoform pain disorder, akathisia, and hypothyroidism are seen in one case each (0.3%). In a total sample of 310 patients, the most common diagnosis was schizophrenia 146 cases (47%) followed by depression 81 cases (26%) [Table 2] and [Figure 1]. The most common indication for the MECT was to augment pharmacotherapy or to speed up the rate of improvement in all the disorders accounting up to 88 cases (60%) and 37 cases (80%) among those with Schizophrenia and Mania respectively [Table 2] and [Figure 2]. Only in case of depression MECT was the first choice indication for around 46 cases (56.8%) of them [Table 2] and [Figure 2]. In these 46 cases MECT was given along with the prescribed medication. Suicidality was the primary symptomatology which led to use of MECT in 72 (23.2%) patients whereas Catatonia was the reason for opting MECT in 34 cases (11%) [Table 3] and [Figure 3]. The mean number of MECTs received in the index episode in most of the disorders was around 6 with a standard deviation of 2 [Table 4]. In overall study population, a response rate of 85% (264 cases) was observed [Table 5] and [Figure 4]. The number of patients in whom MECT was stopped due to complications was 15 (4.6), the complications being cognitive impairment 5 (1.6), headache 3 (0.9), confusion 3 (0.9), nausea 2 (0.6) and fatigue 2 (0.6) [Table 5]. Patient acceptability of MECT was good as only 7 (2.3%) patients withdrew consent after initiation of treatment [Table 5] and [Figure 4]..
Table 1: Sociodemographic and clinical profile of the study participants (n=310)

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Table 2: Indication for the modified electroconvulsive therapy among the various diagnoses

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Figure 1: Distribution of the diagnosis among the subjects who received modified electroconvulsive therapy (n = 310)

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Figure 2: Indication for the modified electroconvulsive therapy among the various diagnoses

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Table 3: Prevalence of catatonia and suicidality as indication for modified electroconvulsive therapy among various diagnoses n (%)

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Figure 3: Prevalence of catatonia and suicidality as indication for modified electroconvulsive therapy among various diagnoses

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Table 4: Number of modified electroconvulsive therapies during the index course in various diagnoses

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Table 5: Reason for stopping modified electroconvulsive therapy in the total study population (n=310)

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Figure 4: Reason for stopping modified electroconvulsive therapy among the study population (n = 310)

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  Discussion Top


The present study attempted to evaluate the prescription patterns of MECT using a retrospective medical record review of 310 patients who received MECT over a 5-year period. Out of the study sample, 161 cases (52%) were male and 149 cases (48%) were female. Around 35 cases (11%) had comorbid substance dependence. Around seven cases (2.3%) had dull-normal intelligence. Less than 1% (n = 3) had comorbid personality disorder.

In this study, most common diagnosis for which MECT was prescribed was schizophrenia 146 cases (47%), and the most common indication was to augment therapy or to speed up the rate of improvement. These findings are consistent with an earlier study conducted on schizophrenia and MECT by Phutane et al.[7] In schizophrenia, a Cochrane review suggests ECT, combined with treatment with antipsychotic drugs, may be considered as an option, particularly when rapid global improvement and reduction of symptoms are desired and also in case of limited response to medication alone.[8] Most common reason for prescribing ECT was to augment pharmacotherapy[8] which is similar to the findings of the current study.

The major indication for MECT in schizophrenia was catatonia in the study done by Phutane et al.[7] which was around 70%. Other studies done on catatonia, it is found that catatonia responds to sedative anticonvulsant treatment (barbiturates and benzodiazepines) and to ECT.[9] ECT is used as second-line management after high-dose benzodiazepine trials.[10] In our study, although catatonia is the major indication for MECT in schizophrenia, the most common diagnosis of our study population, when it comes to the entire study population, suicidality forms the most common indication for the MECT at 72 cases (23.2%), followed by catatonia at 34 cases (11%).

According to a survey conducted in teaching hospitals in Asia in 2001–2003 by Chanpattana et al. patients with schizophrenia received most MECT followed by depression which was 41.8 and 32.4%, respectively.[5] It is similar to the findings of our current study where the most common diagnosis to receive MECT was schizophrenia and depressive disorder at 47 (n = 146) and 26 (n = 81)%, respectively. According to another study conducted in PGI Chandigarh, bipolar disorder was the diagnosis in 18% over a period of 10 years of patients receiving MECT.[11] In our study, over a period of 5 years, 7% (n = 22) was the diagnosis of bipolar disorder among the patients receiving MECT. In mood disorders, before introduction of neuroleptics and mood stabilizers, ECT was one of the mainstays of treatment of both manic and depressive phases of bipolar affective disorder.[11] Studies done by Bharadwaj et al. have also shown that ECT has equal efficacy and leads to similar recovery in unipolar and bipolar depression.[11] It was found that patients with bipolar depression respond faster than those with unipolar depression.[11],[12] Efficacy of ECT in manic phase in terms of remission or marked clinical improvement has been reported to be about 80%.[11],[13] The number of MECTs during the course was 7.36–9.30 in case of bipolar disorder in the same study[11] as compared to 6.4 (2.5) in our study. The mean number of MECTs received in schizophrenia in the study done by Phutane et al.[7] was 8.4 (2.8), whereas in our study, it was 6.3 (2.3). In our study population, a response rate of 85% was observed. The number of patients in whom MECT was stopped due to complications was 15 (4.6), the complications being cognitive impairment 5 (1.6), headache 3 (0.9), confusion 3 (0.9), nausea 2 (0.6), and fatigue 2 (0.6). Patient acceptability of MECT was good as only seven (2.3%) patients withdrew consent after initiation of treatment. Altogether, the current study highlights the prescription patterns, indications, and various reasons for termination of MECTs among different diagnoses. Based on the findings of this study, the role of MECTs for augmenting the pharmacotherapy to speed up the recovery as well as the use of MECTs as a first choice along with the prescribed medication in certain specific indications is recommended.

The limitations of the study are that, although this study looked into the indications and prescription pattern of MECT in various psychiatric disorders, the confounding effect of the medication in these subjects is not considered. The impact of comorbid disorders such as substance use disorders and physical illness on the MECT induced seizures is not looked into. In this study, lack of detailed mention of rating scales to quantify the treatment response and cognitive outcome is another limitation. The retrospective design of our study may be an impediment. Future studies may be done using a prospective design to throw more light into this area. Finally, single-center-based findings of the study would also have an impact on the generalizability of our results. More multicentric studies with a common consensus as per the standard guidelines will contribute further.


  Conclusion Top


Most common diagnosis for which MECT was prescribed was schizophrenia followed by depression. MECT was most commonly used as an augmentation strategy; however, in case of depression, it was used as first line of treatment. Suicidality and catatonia are the common indications for MECT among the study population. Response rate to MECT and acceptability were good in majority. Based on the study findings, the role of MECTs for augmenting the pharmacotherapy to speed up the recovery as well as the use of MECTs as a first choice along with the prescribed medication in certain specific indications is recommended. More studies, in this area at a multicentric level following standard recommendation guidelines would be worthwhile.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Fink M. Meduna and the origins of convulsive therapy. Am J Psychiatry 1984;141:1034-41.  Back to cited text no. 1
    
2.
Gazdag G, Ungvari GS. Electroconvulsive therapy: 80 years old and still going strong. World J Psychiatry 2019;9:1-6.  Back to cited text no. 2
    
3.
Chanpattana W, Kunigiri G, Kramer BA, Gangadhar BN. Survey of the practice of electroconvulsive therapy in teaching hospitals in India. J ECT 2005;21:100-4.  Back to cited text no. 3
    
4.
Gangadhar BN, Phutane VH, Thirthalli J. Research on electroconvulsive therapy in India: An overview. Indian J Psychiatry 2010;52:S362-5.  Back to cited text no. 4
    
5.
Chanpattana W, Kramer BA, Kunigiri G, Gangadhar BN, Kitphati R, Andrade C. A survey of the practice of electroconvulsive therapy in Asia. J ECT 2010;26:5-10.  Back to cited text no. 5
    
6.
Available from: http://publications.nice.org.uk/guidance- on-the-use-of-electroconvulsive-therapy-ta59. [Last accessed on 2013 Dec 05].  Back to cited text no. 6
    
7.
Phutane VH, Thirthalli J, Kesavan M, Kumar NC, Gangadhar BN. Why do we prescribe ECT to schizophrenia patients? Indian J Psychiatry 2011;53:149-51.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Tharyan P, Adams CE. Electroconvulsive therapy for schizophrenia. Cochrane Database of Systematic Reviews 2005(2):CD000076.  Back to cited text no. 8
    
9.
Fink M, Taylor MA. The many varieties of catatonia. Eur Arch Psychiatry Clin Neurosci 2001;251 Suppl 1:18-3.  Back to cited text no. 9
    
10.
Consoli A, Benmiloud M, Wachtel L, Dhossche D, Cohen D, Bonnot O. Electroconvulsive therapy in adolescents with the catatonia syndrome: Efficacy and ethics. J ECT 2010;26:259-65.  Back to cited text no. 10
    
11.
Bharadwaj V, Grover S, Chakrabarti S, Avasthi A, Kate N. Clinical profile and outcome of bipolar disorder patients receiving electroconvulsive therapy: A study from north India. Indian J Psychiatry 2012;54:41-7.  Back to cited text no. 11
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12.
Daly JJ, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, et al. ECT in bipolar and unipolar depression: Differences in speed of response. Bipolar Disord 2001;3:95-104.  Back to cited text no. 12
    
13.
Mukherjee S, Sackeim HA, Schnur DB. Electroconvulsive therapy of acute manic episodes: A review of 50 years' experience. Am J Psychiatry 1994;151:169-76.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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