Electroconvulsive therapy research in psychiatry of old age

This Doctor of Medicine thesis is based on a series of seven published papers examining aspects of electroconvulsive therapy (ECT) that are of interest to old age psychiatrists. Review Papers. Two review papers are included. The first is a systematic review and meta-analysis of bifrontal ECT for depression. Bifrontal electrode placement was developed as a potentially cognitive-sparing alternative to more conventional electrode placements. Our findings suggested that the advantage of bifrontal ECT may lie in a more favourable benefit to cognitive risk profile than both bitemporal and high-dose right unilateral ECT, rather than in its absolute efficacy. Our in-depth review of the role of ictal electroencephalographic (EEG) indices in ECT practice addressed the objective of optimising ECT treatment technique as a means of improving its risk-benefit profile. Our findings suggested that measures of seizure intensity, consistency of EEG pattern over time and postictal suppression can be appraised alongside clinical findings to guide ECT administration. Epidemiological Studies. Our two original epidemiological studies examined ECT use in Victoria, Australia, from 1998 to 2007 based on analysis of statutory data from the Office of the Chief Psychiatrist of Victoria. There first provided an overview of ECT use in young (25-44 years), middle-aged (45-64 years) and older adults (65+ years) and graphically presented ten-year population-adjusted ECT utilisation rates. A higher utilisation rate among older adults was one key finding. The second paper reanalysed this data according to a ‘young-old’ (65-79 years) and ‘old-old’ (80+ years) age division to determine if this pattern was accentuated with increasing age. Age-adjustment of data revealed that old-old adults (women especially) had the highest rate of ECT use overall as well as for depression and public sector treatment. Our findings have clinical and service delivery implications, given the higher medical comorbidity and personal care needs of this population. Clinical Studies. The first of three original clinical research studies examined the rise in the stimulus dose required across a course of moderate-dose right unilateral ECT, as an indirect marker of treatment adequacy among older adults. Our finding that required treatment doses generally did not increase quickly, despite rising seizure thresholds across a treatment course, suggested that moderate-dose ECT cannot be dismissed as a treatment option simply because of the rate of change in electrical stimulation. The second paper examined the impact of ECT on tests of balance and gait, to increase understanding of the potential factors contributing to ECT-related falls in older adults. The absence of any deleterious effect of ECT on balance and gait led us to postulate that post-ECT confusion might actually be a key mediator of ECT-related falls. The final paper compared clinicodemographic characteristics of cognitive test completers and noncompleters from a prior study of the impact of ECT on the cognition of older adults, to determine the likelihood of the results of such studies being widely clinical applicable. Our findings suggested cognitive test nonparticipants to be more severely psychiatrically unwell than test participants, suggesting their exclusion might bias and clinically invalidate study results