Use of electroconvulsive therapy at Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, from 2005 to 2007

Abstracts

INTRODUÇÃO: Este estudo teve como objetivo comparar os dados atuais sobre a eletroconvulsoterapia (ECT) no Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro a dados de estudos anteriores e a pesquisas relacionadas ao tema em outros países. MÉTODO: Foram analisados prontuários de junho de 2005 a junho de 2007, reunindo um total de 69 pacientes que realizaram ECT no período e avaliadas as seguintes categorias: sexo, idade, diagnóstico, indicação e número de aplicações de ECT realizados por paciente. Além disso, foram coletadas informações subjetivas sobre a remissão dos sintomas na evolução desses pacientes. RESULTADOS: Observou-se um predomínio do sexo feminino (71%). A média de idade dos pacientes foi de 41,3 anos (p = 13,7). Os principais diagnósticos encontrados foram esquizofrenia (49,3%) e transtorno afetivo bipolar (27,5%). A indicação mais comum foi a heteroagressividade, seguida da tentativa de suicídio e da auto-agressividade. A média de número de ECT realizados por paciente foi de 8,2. De um modo geral, houve remissão dos sintomas no curto prazo após a realização desse método de tratamento. CONCLUSÃO: As aplicações da ECT no Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro estão de acordo com os critérios e recomendações da Associação Mundial de Psiquiatria e com o modelo utilizado nos países comparados. Houve uma manutenção geral dos padrões utilizados nessa terapêutica no instituto. Além disso, a ECT se mostrou um bom método para remissão de sintomas graves no curto prazo.

Eletroconvulsoterapia; psiquiatria; eficácia; epidemiologia; tratamento

ORIGINAL ARTICLE

Use of electroconvulsive therapy at Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, from 2005 to 2007^*

Daniele Lauriano Pastore;^I Leandro Marchetti Bruno;^I Antonio Egidio Nardi;^II Allan Gonçalves Dias^III

^IMedical student, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.

^IIProfessor. Associate professor, Instituto de Psiquiatria, Faculdade de Medicina, UFRJ, Brazil.

^IIIPsychiatry, Instituto de Psiquiatria, IPUB-UFRJ, Brazil. This study was performed at Panic and Respiration Laboratory and INCT Translational Medicine, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (IPUB-UFRJ), Rio de Janeiro, RJ, Brazil.

Correspondence

ABSTRACT

INTRODUCTION: The objective of this study was to compare current data on electroconvulsive therapy (ECT) at Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro to previous studies and related research in other countries.

METHOD: Medical records of 69 patients who were submitted to ECT were analyzed from June 2005 to June 2007, evaluating the following categories: sex, age, diagnostic, indication and number of ECT sessions each patient received. In addition, subjective information about remission of symptoms was collected in the evolution of these patients.

RESULTS: There was a preponderance of females (71%). Mean age of patients was 41.3 years (p = 13.7). The most frequent diagnoses were schizophrenia (49.3%) and bipolar disorder (27.5%). The most common indication was interpersonal violence, followed by suicide attempt and self-injury. Mean number of ECT sessions received by each patient was 8.2. In general there was remission of symptoms in the short term after using this method.

CONCLUSION: Use of ECT at Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro is in agreement with the criteria and recommendations of the World Psychiatry Association and with the model used in other countries. There was general maintenance of the standards used for this treatment at Instituto de Psiquiatria. Furthermore, ECT proved to be a good method for remission of severe symptoms in the short term.

Keywords: Electroconvulsive therapy, psychiatry, efficacy, epidemiology, treatment.

Introduction

Lack of physiopathologic knowledge and efficacious treatments in early-20^th century psychiatry was such that many scientists started creating all sorts of methods, solely based on observation of few cases and not using a control group. Thus, malariotherapy started by Wagner-Jauregg in 1927,¹ insulin therapy developed by Meduna in 1933¹ and lobotomy performed by Egas Moniz in 1935¹ were created as an attempt to relieve psychotic symptoms, but they certainly induced patients to a greater suffering than their own disease. Even so, the Nobel Prize of Medicine was granted to Wagner-Jauregg and Egas Moniz, the only representatives of psychiatry in this award.

Electroconvulsive therapy (ECT), started by Cerletti & Bini¹ in 1938, was an alternative to treat psychotic patients. However, since then it has been surrounded by criticism and refusals. To date, and without any scientific background, there are still comparisons between induced convulsions in patients and punishment by torture methods, infliction of pain, strong side effects and its mandatory use, with no consent. However, efficacy of such treatment² ensured its survival to all controversies, although psychotropics, since the 1950's, have brought a progressive reduction in its use.

The American Psychiatric Association (APA)³ and the Brazilian Psychiatric Association⁴ are involved with the indication criteria and recommendations in Brazil, and institutions should conform to these guidelines. The importance of evaluating treatments involves the quality assurance of their uses in institutions, by method induction and correct indication.

The APA recommends use of ECT as a first-choice treatment in cases requiring fast remission of acute symptoms, in which the risks of other treatments are higher than those of ECT, refractoriness to drug therapy, good previous response to ECT, or when it is the patient's choice of treatment. In addition, the use as a treatment of second choice, according to the APA, should occur when there is refractoriness of proper treatment, occurrence of severe side effects, or more exacerbated than those caused by ECT and worsening of clinical status.

According to resolution 1640/2002 of the Brazilian Medical Council (CFM),⁵ ECT should be used after assessment of clinical status, exclusively performed by a physician at a hospital setting. Anesthesia is mandatory (CFM Resolution 1363/1993). According to bioethical principles, the patient or his family should sign an informed consent; physicians may apply this therapy in case the consent cannot be obtained. In this case, the physician is responsible for the treatment. However, there is no protocol standardized by CFM for number of ECT sessions. Treatment maintenance depends on patient assessment after each session.

Because it is an experimental method, based on clinical observation, ECT needs parameters to remain efficacious and safe.⁶ To do so, it is relevant to evaluate time of convulsion, number of applications, patients' profile (age, gender and diagnosis), and data such as mortality rate and complications.

The Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB-UFRJ) has been using ECT since 1946. However, only a few studies on this theme have been published by this institution: Nardi & Figueira⁷ conducted an epidemiologic survey comprehending 1961-1965 and 1979-1983, Miranda et al.⁸ aimed at performing a critical and qualitative evaluation of its use, and Alves et al.⁹ evaluated the demographic and clinical profile of a group of patients at IPUB-UFRJ. Therefore, for nearly 20 years there has been a clear need of performing a current evaluation to maintain this institution as a Brazilian reference center in the formation of professionals, in conformity with international standards.

The patient's profile undergoing ECT at IPUB-UFRJ was evaluated, as well as the criteria of ECT use, focusing on indications, methodology and results, and comparing patients before and after the treatment. In addition, comparisons were performed using data obtained from eight countries (USA, Australia, Germany, Hungary, Japan, India, Russia, and Belgium) and from other Brazilian studies.

Method

Data were collected from 69 nursing patients and outpatients of IPUB-UFRJ from June 2005 to June 2007. PubMed¹⁰ and Capes¹¹ databases were searched for available retrospective and epidemiological studies on use of ECT in Brazil, in other countries and at IPUB-UFRJ in Portuguese, English, French, and German.

A retrospective study of that period was performed, restricted to epidemiological data relative to age, gender, number of ECT sessions, diagnosis according to the International Statistical Classification of Diseases and Related Health Problems, 10th edition (ICD-10), and indication for ECT. All patients submitted to ECT during the study period were included.

Results

All applications relative to 69 patients were bilateral; propofol or alfentanil were used as anesthetics, and succinylcholine as muscle relaxant. Clonidine was used in hypertensive patients to avoid possible hypertensive peaks during sessions. The EMAI device was used. Side effects were mild and transient, such as retrograde amnesia, disorientation, and headache. Myalgia, nausea and fatigue were rare. There were no deaths.

The session protocol at IPUB-UFRJ is as follows: the first three applications are performed in consecutive days. Later, up to eight applications are performed in alternate days. The following applications are performed twice or three times a week. Each patient receives an average of eight applications. The series is interrupted when the patient recovers from acute symptoms of the disorder.

The female gender was predominant in ECT application, accounting for 71% of the total (49 women), compared with 29% of men (20). There was also a higher number of women in all nosological entities analyzed alone (Table 1).

The Table relates patient's diagnosis according to ICD-10 and their gender. The female gender was predominant in all diagnoses.

As to diagnosis according to ICD-10, schizophrenia was predominant (F20), affecting 34 out of 69 patients (about 49.3%). Other diagnoses were bipolar affective disorder (F31) in 27.5%; moderate depressive episode (F32.1) in 10.1%; recurrent depressive disorder, current severe episode with psychotic symptoms (F33.3) in 5.8%; unspecified non-organic psychosis (F29) in 5.8%, and mania with psychotic symptoms (F30.2) in 1.45% of all patients, all with approximate values (Figure 1).

As to indications for ECT, 22.5% were due to heteroaggressiveness, 15.7% due to suicide attempt, 13.5% due to self-aggressiveness, 13.5% due to refractoriness to psychotropics, 9% due to severe schizophrenia, 9% due to severe depression, 6.7% due to severe mania, 6.7% due to catatonia, and 3.4% due to pregnancy. It is worth stressing that, in some cases, there was more than one indication; in total there were 89 indications (Figure 2).

As to patients' age, 20.3% were in the age group 18-29 years, 31.9% between 30-39 years and 47.8% were older than 40 years (approximate values). Mean age of patients was 41.3 years (p = 13.79).

Analysis of number of ECT sessions performed by each patient showed that in 34.8% of cases fewer than five sessions were applied; in 33.3%, between five and nine sessions; in 15.9%, between 10 and 14; in 7.3%, between 15 and 19; and in 8.7% of cases, more than 20 sessions, approximately (Figure 3).

Discussion

Studies that performed an epidemiological analysis similar to this at IPUB-UFRJ collected data in 1961-1965,⁷ 1979-1983,⁷ 1994-1995,⁸ and 2003.⁹ Over the first period there was a 1:1.6 ratio between men and women submitted to ECT, and number of doses was not homogeneous, ranging between one to twenty applications. Schizophrenia was the most commonly indicated diagnosis for this therapy. From 1979 to 1983, the man:woman ratio went to 1:1.9, and doses became more homogenous, most cases having between five and eight applications. The most commonly indicated diagnosis for ECT was still schizophrenia. From April 1994 to August 1995 there was a higher man:woman ratio: 1:2.7. Schizophrenia was again the predominant diagnosis, but there was an increase in diagnoses of mood disorders. Mean was six sessions per patient and predominant age group was 25-30 years. Over the last period, 32 patients were analyzed, and a man:woman ratio of 1:1.9 was obtained; the most frequent diagnosis for indication of ECT was bipolar disorder.

A study conducted by Volpe et al. from 1996 to 2000 at a private hospital in Belo Horizonte, Minas Gerais,¹² included a sample of 269 inpatients with manic or mixed episode. Frequency of ECT was 33.2% in relation to other treatments.

In Europe, studies found depression as the most frequent diagnosis^13-15 (Belgium, 89.7 and 88%; Germany, 44.3%), except for Hungary,¹⁶ where schizophrenia was predominant (40.4%). Mean ECT sessions used in Hungary was 9.3 sessions per patient, similar to Russia¹⁷ (8.1 sessions) and Germany¹⁵ (10.7 sessions).

An Australian study of 1,535 patients found 62.8% prevalence of female gender. Diagnosis of depression was highly indicated for ECT (75.2%). Mean applications was 12 for affective disorders and 4.5 for schizophrenia. Patients' age group was 32.9% for those older than 64 years.¹⁸

Another study¹⁹ performed in Australia evaluated 1,469 patients. Affective disorders were more frequent than other disorders. Most patients had only one ECT session (61.6%), and the female gender predominated (65%). The most frequent age group among patients was 19-64 years (70.7%), with mean age of 50 years (p = 18.85).

In Japan, 1,210 patients were analyzed; most of them were women (53.7%), aged 45-64 years (40.4%). Mean ECT sessions over the period was 9.1, and the most frequent diagnosis was schizophrenia.²⁰

In India the number of patients in the sample was higher (19,632) and, differently from all other studies, men were predominant (1.6:1). This might be due to a higher incidence of mood disorders in women and to more hospitalizations with ECT treatment for patients with different diagnoses, such as schizophrenia. As in Japan, schizophrenia was the most frequent diagnosis in India, and age group was between 45 and 64 years. Mean number of sessions per patient was 5.4.²¹

In California, USA, a similar observation was performed from 1977 to 1983, including a total of 18,627 patients. Of these, 69% are female, aged more than 25 years, most of them older than 45 years.²² In New York the study was conducted at three intervals: 1961-1965, 1966-1970 and 1971-1975. Depression was the predominant diagnosis at all intervals. Results varied as to predominant gender: over the first years, man:woman ratio was 1:2.5; in the second analysis, such ratio fell to 1:2, and in the last period it was 1:1.7.²³

A study conducted by Mayo Clinic Rochester (Minnesota, USA) showed that 87.3% of patients using ECT answered "I am happy for having been submitted to ECT" in a questionnaire applied to 24 patients.²⁴ This is extremely relevant for this study, as it shows that such treatment is well accepted by the patient and has good outcomes.

The IPUB-UFRJ is the only institution to provide ECT in the State of Rio de Janeiro, providing care to patients coming from varied locations. Therefore, it is a good study model of the profile in Rio de Janeiro.

Schizophrenia accounts for the highest incidence of hospitalization diagnoses in this psychiatric center, followed by bipolar disorder. Because it is a tertiary hospital, IPUB-UFRJ admits severe cases, such as acute and drug-refractory schizophrenia. This reflects in the diagnostic pattern of patients referred to perform ECT, as found in the results of this study.

Salleh et al.,⁶ in a literature review, concluded that maintenance of medication during ECT sessions has faster results than its use alone. It brings a therapeutical advantage, ensures patients' and health professionals' safety, and facilitates nursing management. It is relevant to stress medications that are not prescribed in combination with ECT, such as monoamine oxidase inhibitor antidepressants, lithium carbonate, and anticonvulsants. In addition, IPUB-UFRJ, for being a free institution, receives a considerable number of patients brought by third parties after causing damage to public order or themselves. Such offensive behaviors might be related to the profile of patients hospitalized in this type of entity. The findings of this sample corroborate such reasoning, as heteroaggressiveness, suicide attempt and self-aggressiveness were found as the most frequent indications for ECT use.

The female gender was predominant both absolutely and relatively to diagnoses alone. Patients diagnosed with current severe episode with psychotic symptoms and moderate depressive episode according to the ICD-10 had a man:woman ratio of 1: 3 and 1: 1.3. This can be explained by the fact that such disorders are more frequent in female patients.²⁵

Although schizophrenia²⁶ and bipolar disorder²⁷ do not have a statistically smaller man:woman ratio, females were predominant in these diagnoses.

This study showed a total man: woman ratio of 1:2.5. Such results are compatible with those found in other countries and cities, such as in New York (1:2.5),²³ California (1:2.2),²² Australia (1:1.7 and 1:1.8)^18,19 and Brazil (1:1.9 and 1:2.7).^7,8 India was the only country to have an inverse relationship (1:1.61).²¹ Studies in Germany and Russia do not report data on this relationship.

In most cases (49.3%), diagnosis was schizophrenia, with a man: woman ratio of 1:1.8. The likely reason for this might be female predominance in relation to men at IPUB-UFRJ.

With regard to findings relative to diagnosis, there was maintenance of percentage superiority of schizophrenics at IPUB-UFRJ, as previously shown by Nardi & Figueira⁷ and Miranda et al. ⁸. The same pattern is seen in countries such as Japan,²⁰ Hungary¹⁶ and India.²¹ However, there was a difference in results found in Australia,^18,19 Germany,¹⁵ Belgium^14,15 and the USA,^22,23 which showed higher values for diagnoses of depression.

Analysis of indications for ECT use in many countries showed a lack of data on this issue, since many articles consider indications as diagnoses. Thus, refractoriness was the most frequent justification for ECT in such places, opposed to heteroaggressiveness found in this sample. In this study, the criterion "indication" was adopted as medical background to perform ECT. This was performed because we believe that diagnosis alone is not enough to refer patients to this type of treatment.

Salleh et al.⁶ reported that number of sessions required to treat depression ranges between six and eight applications, and may reach 12 in more severe cases. This is an agreement with means found in Russia,¹⁰ Germany,¹⁵ Australia^18,19 and the USA,^22,23 where the most frequent diagnoses are depression-related disorders.

There was an agreement between the worldwide profile and that found at IPUB-UFRJ regarding the age group of patients submitted to ECT: more patients are aged more than 40 years. In the sample, this category accounts for 47.8%, similar to Japan²⁰ (40.4%) and India²¹ (43.9%).

In countries where depression is predominant,^18,19,23,24 the age group of patients submitted to ECT is reasonably higher than that found in Brazil,^7,8,12 Japan²⁰ and India,²¹ where there was higher diagnostic prevalence of schizophrenia. This can be explained by earlier occurrence of schizophrenia compared with depression.

Limitations of this study include small sample size and short analysis period. In addition, it is worth stressing that evaluation of patients' evolution in terms of treatment is subjective, as it depends on the physician's clinical observation, which results in another limitation to this study relative to objective evaluation of ECT as a method.

Conclusions

This study evaluated use of ECT as a treatment at IPUB-UFRJ. All the applications were in agreement with the criteria and recommendations of the World Psychiatry Association⁶ and with the model used in other countries.

Although it is still a controversial issue, use of ECT remains as a good method for remission of severe symptoms, such as those of the patients included in this sample.

This study shows an overall maintenance of the standards used in ECT at IPUB-UFRJ for the categories evaluated qualitatively. As there are considerably disagreeing results between number of sessions given to each patient in analyzed countries, maintenance of ECT sessions seems to be chosen by the physician's subjective evaluation. Therefore, there is a lack of a common model for ECT use. This reinforces the need of further studies focused on the development of a standard of applications necessary to a good response by patients submitted to the treatment.

Acknowledgments

To nurse Rita de Simões; to CIPE secretary, Mr. Dario; to billing secretary, Cíntia; to outpatient clinic secretary, Mr. Álvaro and to all patients that directly or indirectly contributed to this study.

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*

Este estudo foi realizado no Laboratório de Pânico e Respiração, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (IPUB-UFRJ), Rio de Janeiro, RJ.

Publication Dates

• Publication in this collection
  17 Mar 2009
• Date of issue
  Dec 2008

History

• Accepted
  09 Sept 2008
• Received
  14 July 2008