ORIGINAL STUDY
Acute Electroconvulsive Therapy Followed by Maintenance Electroconvulsive Therapy Decreases Hospital Re-Admission Rates of Older Patients With Severe Mental Illness Assaf Shelef, MD, MHA,*† Doron Mazeh, MD,*† Uri Berger, MA,‡ Yehuda Baruch, MD, MHA,*† and Yoram Barak, MD, MHA*† Objectives: Electroconvulsive therapy (ECT) is a highly effective treatment for patients with severe mental illness (SMI). Maintenance ECT (M-ECT) is required for many elderly patients experiencing severe recurrent forms of mood disorders, whereas M-ECT for schizophrenia patients is a poorly studied treatment. We report on the outcomes in aged patients with SMI: schizophrenia and severe affective disorders treated by M-ECT of varying duration to prevent relapse after a successful course of acute ECT. The study measured the effectiveness of M-ECT in preventing hospital readmissions and reducing admission days. Method: A retrospective chart review of 42 consecutive patients comparing the number and length of psychiatric admissions before and after the start of M-ECT was used. We analyzed diagnoses, previous ECT treatments, number of ECT treatments, and number and length of psychiatric admissions before and after M-ECT. Results: Mean age in our sample was 71.5 (6.9) years. Twenty-two (52%) patients experienced severe affective disorders and 20 (48%) experienced schizophrenia. Patients were administered 92.8 (85.9) M-ECT treatments. Average duration of the M-ECT course was 34 (29.8) months. There were on average 1.88 admissions before M-ECT and only 0.38 admissions in the M-ECT period (P < 0.001). Duration of mean hospitalization stay decreased from 215.9 to 12.4 days during the M-ECT (P < 0.01). Conclusions: Our findings suggest that acute ECT followed by M-ECT is highly effective in selected elderly patients with SMIs. Key Words: maintenance ECT, elderly, schizophrenia, affective disorders, severe mental illness (J ECT 2015;31: 125–128)
R
elapse rates after discontinuation of electroconvulsive therapy (ECT) are considered very high. Maintenance ECT (M-ECT) is an underused treatment option that can substantially reduce risks of relapse in patients with severe mental illnesses (SMIs) such as major depressive disorder, bipolar disorder, and schizophrenia.1 Recently, Jelovac and colleagues2 analyzed all publications evaluating the effectiveness of relapse prevention by M-ECT and antidepressants: 6 months after ECT for major depression, over a third of people taking maintenance antidepressants have relapsed and similar relapse rates were seen for people receiving M-ECT. Nevertheless, maintenance antidepressants significantly reduce the risk of relapse compared with placebo. To the best of our knowledge, no M-ECT studies have focused on elderly SMI patients. The use of polypharmacy, comorbid physical disorders, and decreased response to standard
From the *Abarbanel Mental Health Center, Bat-Yam; †Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; and ‡Department of Psychology, Bar-Ilan University, Ramat-Gan, Israel. Received for publication March 7, 2014; accepted September 25, 2014. Reprints: Assaf Shelef, MD, MHA, Abarbanel Mental Health Center, 15 KKL St, Bat-Yam 59100, Israel (e‐mail: [email protected]). The authors have no conflicts of interest or financial disclosures to report. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000197
antidepressants regimens make the elderly an especially attractive group to study in the context of M-ECT. The elderly patients experiencing mood disorders are frequently challenged by chronic relapsing illnesses and thus the evaluation of relapse prevention strategies is crucial.3 Patients with severe mood disorders, for which treatment with ECT is indicated, often remit after an acute course of ECT.4–6 Having achieved remission of the index depressive episode, it is sensible to consider continuation ECT or M-ECT to prevent relapse of the current episode or recurrence of a new episode, respectively.6 However, the terms continuation ECT and M-ECT are often used interchangeably and indiscriminately when describing the use of ECT after remission of the acute episode.4–6 Results from the few studies assessing the influence of age on the efficacy of ECT were inconsistent and ECT seemed to be equally efficacious in all age groups.7 Schizophrenia patients who are treated with ECT have more severe illnesses, have had longer illness durations, and have been through more treatment attempts than other schizophrenia patients.8 Electroconvulsive therapy is efficacious on different schizophrenia symptoms, for instance, psychotic core symptoms, affective symptoms, and suicidality.9 Maintenance ECT combined with an antipsychotic may be beneficial in patients who responded to acute ECT and in whom pharmacological maintenance alone is ineffective or not tolerated.8–15 There is yet no consensus on the optimal treatment interval, or when M-ECT should be terminated. The present study aimed to evaluate the effectiveness of MECT in preventing hospital readmissions and reducing admission days in a group of elderly patients with SMI.
METHODS For the purpose of this report, we will use the following definitions: an index/acute course are the initial series of treatments given for the purpose of relieving acute symptoms of the depressive episode. In accordance with Rabheru,1 we defined all treatments after achieving remission of the index depressive episode as MECT in the following manner: an ECT course that begins after the end of acute ECT treatment and is intended to prevent both relapse and recurrence of an episode (a new episode). This is also in line with the following comment recently published by O'Connor and colleagues16: “In Australia, psychiatrists tend to refer to all ongoing, typically ambulatory, treatments as maintenance ECT. The term continuation ECT, referring to post-acute treatment not extending beyond 6 months, is not in common usage….” After an acute ECT course, M-ECT is offered in our department to elderly patients with SMI according to the following inclusion criteria: (a) History of drug resistance (b) Intolerable adverse effects to drug treatment (c) Admission due to extreme suicidal behavior (d) Admission due to catatonia (e) History of escalating frequency of readmissions (f) Physical comorbidity incompatible with drug treatment.
Journal of ECT • Volume 31, Number 2, June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ectjournal.com
125
Journal of ECT • Volume 31, Number 2, June 2015
Shelef et al
“History of drug resistance” was defined as not achieving remission with 3 antidepressants of 2 different chemical groups or 3 antipsychotics of both first and second generation. “History of escalating frequency of readmissions” was defined as 3 admissions in the 2 years before the index hospitalization. “Physical comorbidities incompatible with drug treatment” were defined as conditions that were contraindicated for psychotropic drug treatment by a specialist in internal medicine such as immune suppression, severe incapacitating extrapyramidal symptoms, and others. It is important to note that “remission” of the index depressive episode and thus the termination of acute ECT treatments were based on the physician's rating of the Clinical Global Impressionseverity (CGI-s) scale.17 Patients completed the acute ECT course only when CGI-s score of 1 (normal, not at all ill) or 2 (borderline mentally ill) was achieved. To meet the remission criterion for the index episode, patients need to be rated with a CGI-s of 1 or 2 in 2 consecutive clinical evaluations 1 week apart. Exclusion criteria are the following: (a) Minor or major cognitive impairment (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) (b) Patient's refusal (c) Lack of familial or social support necessary to comply with the logistics of M-ECT. We used a retrospective chart review design to analyze records for the period January 2001 to December 2011. Documented details regarding all ECT treatments during the acute phase and the maintenance phase were analyzed. We included patients who had been receiving M-ECT for a minimum of 6 months after the acute treatment phase. It is of note that M-ECT was administered to patients already living in the community. Decisions regarding M-ECT dosing schedule and duration were made on a case-by-case basis by the treating senior psychiatrist. The data analyzed were patients' age; accommodation; sex; marital status; psychiatric and medical history; number and
TABLE 1. Patient Characteristics at Start of Acute ECT Treatment Age, mean (SD) [range], y Sex, n (%) Female Marital status, n (%) Married Bachelor Divorced Widow Accommodation, n (%) Home Nursing home Psychiatric diagnosis, n (%) Severe psychotic unipolar depression Severe nonpsychotic unipolar depression Bipolar affective disorder Schizophrenia Duration of illness, mean (SD) [range], y No. previous hospitalizations, mean (SD) [range] Legal status of acute ECT, n (%) Involuntary Medical comorbidity (mean number of conditions)
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71.54 (6.96) [60–83] 29 (69) 27 (64) 4 (9) 3 (7) 8 (18) 39 (93) 3 (7) 14 (33.3) 6 (14.2) 2 (4) 20 (48) 22.4 (16.4) [1–63] 6.14 (6.99) [0–30]
6 (14) 1.38 (1.2)
TABLE 2. Acute ECT Indications, Previous ECT Courses, Number of ECT Treatments, and Duration of ECT Indication, n (%) Severe agitation Refusal to eat or drink Catatonia Drug refractoriness Suicidality Aggressiveness No. previous acute ECT courses No. ECT treatments [range] Duration of ECT treatment [range], mo
18 (42.8) 15 (35.7) 11 (26.1) 11 (26.1) 13 (30.9) 7 (16.6) 0.61 (1.08) 92.8 (85.89) [16–364] 34 (29.8) [6–116]
duration of ECT treatments; and detailed reasons for prescribing acute ECT course and previous ECT treatments (both acute and M-ECT) and their effect, adverse events, reasons for stopping ECT, and patient attitudes toward the acute ECT (index) course. The study's outcomes were the number of admissions and duration of inpatient stay. We compared these outcomes between the periods preceding the index ECT phase and the M-ECT phase. We compared number of admissions and inpatient stay for the actual period during which ECTwas administered (acute phase ECT plus M-ECT) with the exact period preceding the index ECT phase. For example, in the case of a patient given acute phase ECT plus M-ECT over a span of 8 months, the comparison period refers to the 8 months before the ECT treatment.
Statistics To examine differences attributed to mental disorder type, 2 analyses of variance (ANOVA) with repeated measures were carried out. The independent factors were disorder type (schizophrenia/ affective disorder) by time (before/after admission) once examined with number of admissions as the dependent factor and once with days of admissions. In both analyses, no interactions were obtained for disorder type and time; therefore, we collapsed the data over disorder type and proceeded to analyze the time differences with a simple t test analysis.
RESULTS Patient Characteristics Table 1 gives the demographic and clinical characteristics for the total sample. During the study period, 91 elderly SMI patients had been treated and responded to acute phase ECT. Maintenance ECT was recommended to 78 responding patients who fulfilled inclusion criteria. Forty-two (53.84%) of 78 patients agreed to continue with M-ECT, 29 women and 13 men, mean age of 71.5 years (range, 60-83 years). Fifty-two percent experienced severe affective disorder and 48% experienced schizophrenia. Most of the patients were women. Most lived at home, 40.4% had prior acute ECT course in their past, but only 9.5% of the patients had experienced prior M-ECT.
Electroconvulsive Therapy Acute ECT was administered when drug treatment had no effect; rapid improvement was needed, as in life-threatening conditions and in the face of deteriorating medical condition. Indications for acute ECT treatment were severe agitation, refuse to drink or eat, severe suicidality, catatonia, refractoriness to drug therapy, and aggressive behavior (Table 2).Patients were treated © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Journal of ECT • Volume 31, Number 2, June 2015
Acute ECT and M-ECT Decreases Hospitalizations
TABLE 3. Number of Psychiatric Admissions and Hospitalization Days Before and During M-ECT Period [Mean (SD), 34 (29.8) Months] t
Before M-ECT During M-ECT Admission (n) 1.88 (0.237) Admission, d 215.93 (461.95)
0.38 (0.113) 12.45 (29.66)
df
P
5.67 41
Acute Electroconvulsive Therapy Followed by Maintenance Electroconvulsive Therapy Decreases Hospital Re-Admission Rates of Older Patients With Severe Mental Illness Assaf Shelef, MD, MHA,*† Doron Mazeh, MD,*† Uri Berger, MA,‡ Yehuda Baruch, MD, MHA,*† and Yoram Barak, MD, MHA*† Objectives: Electroconvulsive therapy (ECT) is a highly effective treatment for patients with severe mental illness (SMI). Maintenance ECT (M-ECT) is required for many elderly patients experiencing severe recurrent forms of mood disorders, whereas M-ECT for schizophrenia patients is a poorly studied treatment. We report on the outcomes in aged patients with SMI: schizophrenia and severe affective disorders treated by M-ECT of varying duration to prevent relapse after a successful course of acute ECT. The study measured the effectiveness of M-ECT in preventing hospital readmissions and reducing admission days. Method: A retrospective chart review of 42 consecutive patients comparing the number and length of psychiatric admissions before and after the start of M-ECT was used. We analyzed diagnoses, previous ECT treatments, number of ECT treatments, and number and length of psychiatric admissions before and after M-ECT. Results: Mean age in our sample was 71.5 (6.9) years. Twenty-two (52%) patients experienced severe affective disorders and 20 (48%) experienced schizophrenia. Patients were administered 92.8 (85.9) M-ECT treatments. Average duration of the M-ECT course was 34 (29.8) months. There were on average 1.88 admissions before M-ECT and only 0.38 admissions in the M-ECT period (P < 0.001). Duration of mean hospitalization stay decreased from 215.9 to 12.4 days during the M-ECT (P < 0.01). Conclusions: Our findings suggest that acute ECT followed by M-ECT is highly effective in selected elderly patients with SMIs. Key Words: maintenance ECT, elderly, schizophrenia, affective disorders, severe mental illness (J ECT 2015;31: 125–128)
R
elapse rates after discontinuation of electroconvulsive therapy (ECT) are considered very high. Maintenance ECT (M-ECT) is an underused treatment option that can substantially reduce risks of relapse in patients with severe mental illnesses (SMIs) such as major depressive disorder, bipolar disorder, and schizophrenia.1 Recently, Jelovac and colleagues2 analyzed all publications evaluating the effectiveness of relapse prevention by M-ECT and antidepressants: 6 months after ECT for major depression, over a third of people taking maintenance antidepressants have relapsed and similar relapse rates were seen for people receiving M-ECT. Nevertheless, maintenance antidepressants significantly reduce the risk of relapse compared with placebo. To the best of our knowledge, no M-ECT studies have focused on elderly SMI patients. The use of polypharmacy, comorbid physical disorders, and decreased response to standard
From the *Abarbanel Mental Health Center, Bat-Yam; †Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; and ‡Department of Psychology, Bar-Ilan University, Ramat-Gan, Israel. Received for publication March 7, 2014; accepted September 25, 2014. Reprints: Assaf Shelef, MD, MHA, Abarbanel Mental Health Center, 15 KKL St, Bat-Yam 59100, Israel (e‐mail: [email protected]). The authors have no conflicts of interest or financial disclosures to report. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000197
antidepressants regimens make the elderly an especially attractive group to study in the context of M-ECT. The elderly patients experiencing mood disorders are frequently challenged by chronic relapsing illnesses and thus the evaluation of relapse prevention strategies is crucial.3 Patients with severe mood disorders, for which treatment with ECT is indicated, often remit after an acute course of ECT.4–6 Having achieved remission of the index depressive episode, it is sensible to consider continuation ECT or M-ECT to prevent relapse of the current episode or recurrence of a new episode, respectively.6 However, the terms continuation ECT and M-ECT are often used interchangeably and indiscriminately when describing the use of ECT after remission of the acute episode.4–6 Results from the few studies assessing the influence of age on the efficacy of ECT were inconsistent and ECT seemed to be equally efficacious in all age groups.7 Schizophrenia patients who are treated with ECT have more severe illnesses, have had longer illness durations, and have been through more treatment attempts than other schizophrenia patients.8 Electroconvulsive therapy is efficacious on different schizophrenia symptoms, for instance, psychotic core symptoms, affective symptoms, and suicidality.9 Maintenance ECT combined with an antipsychotic may be beneficial in patients who responded to acute ECT and in whom pharmacological maintenance alone is ineffective or not tolerated.8–15 There is yet no consensus on the optimal treatment interval, or when M-ECT should be terminated. The present study aimed to evaluate the effectiveness of MECT in preventing hospital readmissions and reducing admission days in a group of elderly patients with SMI.
METHODS For the purpose of this report, we will use the following definitions: an index/acute course are the initial series of treatments given for the purpose of relieving acute symptoms of the depressive episode. In accordance with Rabheru,1 we defined all treatments after achieving remission of the index depressive episode as MECT in the following manner: an ECT course that begins after the end of acute ECT treatment and is intended to prevent both relapse and recurrence of an episode (a new episode). This is also in line with the following comment recently published by O'Connor and colleagues16: “In Australia, psychiatrists tend to refer to all ongoing, typically ambulatory, treatments as maintenance ECT. The term continuation ECT, referring to post-acute treatment not extending beyond 6 months, is not in common usage….” After an acute ECT course, M-ECT is offered in our department to elderly patients with SMI according to the following inclusion criteria: (a) History of drug resistance (b) Intolerable adverse effects to drug treatment (c) Admission due to extreme suicidal behavior (d) Admission due to catatonia (e) History of escalating frequency of readmissions (f) Physical comorbidity incompatible with drug treatment.
Journal of ECT • Volume 31, Number 2, June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ectjournal.com
125
Journal of ECT • Volume 31, Number 2, June 2015
Shelef et al
“History of drug resistance” was defined as not achieving remission with 3 antidepressants of 2 different chemical groups or 3 antipsychotics of both first and second generation. “History of escalating frequency of readmissions” was defined as 3 admissions in the 2 years before the index hospitalization. “Physical comorbidities incompatible with drug treatment” were defined as conditions that were contraindicated for psychotropic drug treatment by a specialist in internal medicine such as immune suppression, severe incapacitating extrapyramidal symptoms, and others. It is important to note that “remission” of the index depressive episode and thus the termination of acute ECT treatments were based on the physician's rating of the Clinical Global Impressionseverity (CGI-s) scale.17 Patients completed the acute ECT course only when CGI-s score of 1 (normal, not at all ill) or 2 (borderline mentally ill) was achieved. To meet the remission criterion for the index episode, patients need to be rated with a CGI-s of 1 or 2 in 2 consecutive clinical evaluations 1 week apart. Exclusion criteria are the following: (a) Minor or major cognitive impairment (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) (b) Patient's refusal (c) Lack of familial or social support necessary to comply with the logistics of M-ECT. We used a retrospective chart review design to analyze records for the period January 2001 to December 2011. Documented details regarding all ECT treatments during the acute phase and the maintenance phase were analyzed. We included patients who had been receiving M-ECT for a minimum of 6 months after the acute treatment phase. It is of note that M-ECT was administered to patients already living in the community. Decisions regarding M-ECT dosing schedule and duration were made on a case-by-case basis by the treating senior psychiatrist. The data analyzed were patients' age; accommodation; sex; marital status; psychiatric and medical history; number and
TABLE 1. Patient Characteristics at Start of Acute ECT Treatment Age, mean (SD) [range], y Sex, n (%) Female Marital status, n (%) Married Bachelor Divorced Widow Accommodation, n (%) Home Nursing home Psychiatric diagnosis, n (%) Severe psychotic unipolar depression Severe nonpsychotic unipolar depression Bipolar affective disorder Schizophrenia Duration of illness, mean (SD) [range], y No. previous hospitalizations, mean (SD) [range] Legal status of acute ECT, n (%) Involuntary Medical comorbidity (mean number of conditions)
126
www.ectjournal.com
71.54 (6.96) [60–83] 29 (69) 27 (64) 4 (9) 3 (7) 8 (18) 39 (93) 3 (7) 14 (33.3) 6 (14.2) 2 (4) 20 (48) 22.4 (16.4) [1–63] 6.14 (6.99) [0–30]
6 (14) 1.38 (1.2)
TABLE 2. Acute ECT Indications, Previous ECT Courses, Number of ECT Treatments, and Duration of ECT Indication, n (%) Severe agitation Refusal to eat or drink Catatonia Drug refractoriness Suicidality Aggressiveness No. previous acute ECT courses No. ECT treatments [range] Duration of ECT treatment [range], mo
18 (42.8) 15 (35.7) 11 (26.1) 11 (26.1) 13 (30.9) 7 (16.6) 0.61 (1.08) 92.8 (85.89) [16–364] 34 (29.8) [6–116]
duration of ECT treatments; and detailed reasons for prescribing acute ECT course and previous ECT treatments (both acute and M-ECT) and their effect, adverse events, reasons for stopping ECT, and patient attitudes toward the acute ECT (index) course. The study's outcomes were the number of admissions and duration of inpatient stay. We compared these outcomes between the periods preceding the index ECT phase and the M-ECT phase. We compared number of admissions and inpatient stay for the actual period during which ECTwas administered (acute phase ECT plus M-ECT) with the exact period preceding the index ECT phase. For example, in the case of a patient given acute phase ECT plus M-ECT over a span of 8 months, the comparison period refers to the 8 months before the ECT treatment.
Statistics To examine differences attributed to mental disorder type, 2 analyses of variance (ANOVA) with repeated measures were carried out. The independent factors were disorder type (schizophrenia/ affective disorder) by time (before/after admission) once examined with number of admissions as the dependent factor and once with days of admissions. In both analyses, no interactions were obtained for disorder type and time; therefore, we collapsed the data over disorder type and proceeded to analyze the time differences with a simple t test analysis.
RESULTS Patient Characteristics Table 1 gives the demographic and clinical characteristics for the total sample. During the study period, 91 elderly SMI patients had been treated and responded to acute phase ECT. Maintenance ECT was recommended to 78 responding patients who fulfilled inclusion criteria. Forty-two (53.84%) of 78 patients agreed to continue with M-ECT, 29 women and 13 men, mean age of 71.5 years (range, 60-83 years). Fifty-two percent experienced severe affective disorder and 48% experienced schizophrenia. Most of the patients were women. Most lived at home, 40.4% had prior acute ECT course in their past, but only 9.5% of the patients had experienced prior M-ECT.
Electroconvulsive Therapy Acute ECT was administered when drug treatment had no effect; rapid improvement was needed, as in life-threatening conditions and in the face of deteriorating medical condition. Indications for acute ECT treatment were severe agitation, refuse to drink or eat, severe suicidality, catatonia, refractoriness to drug therapy, and aggressive behavior (Table 2).Patients were treated © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Journal of ECT • Volume 31, Number 2, June 2015
Acute ECT and M-ECT Decreases Hospitalizations
TABLE 3. Number of Psychiatric Admissions and Hospitalization Days Before and During M-ECT Period [Mean (SD), 34 (29.8) Months] t
Before M-ECT During M-ECT Admission (n) 1.88 (0.237) Admission, d 215.93 (461.95)
0.38 (0.113) 12.45 (29.66)
df
P
5.67 41
