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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 4  |  Page : 373-378  

Efficacy of electroconvulsive therapy and its impact on quality of life of patient: A longitudinal study


Department of Psychiatry, Dr. DY Patil Medical College, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission02-Aug-2019
Date of Decision16-Oct-2019
Date of Acceptance11-Mar-2020
Date of Web Publication20-Jul-2020

Correspondence Address:
Suprakash Chaudhury
Department of Psychiatry, Dr. DY Patil Medical College, Dr. DY Patil Vidyapeeth, Pimpri, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_224_19

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  Abstract 


Background: Electroconvulsive therapy (ECT) decreases the morbidity in psychiatric illnesses, reduces drug requirement during maintenance, which leads to improvement in quality of life (QOL) in a shorter duration of time. Aim: This study aims to evaluate the efficacy of ECT and its impact on the QOL in patients suffering from affective disorders and schizophrenia treated with ECT and pharmacotherapy compared to patients treated with pharmacotherapy alone. Materials and Methods: Thirty consecutive patients diagnosed as per ICD 10 DCR criteria suffering from affective disorder or schizophrenia admitted to the psychiatric ward of a tertiary care hospital needing ECT were compared with equal number of age, sex, and diagnosis matched patients treated by medication alone. All patients gave informed consent. Pro forma containing demographic and clinical details was recorded. Positive and negative syndrome scale, Beck's Depression Inventory II, and short form-36 (SF-36) were applied to all the individuals at the time of admission, 3 months' and 6 months' post-ECT. Results: The ECT group showed a significant improvement in severity and QOL at 3 months' follow up (P < 0.0001), followed by a steady continuation in improvement at 6 months as compared to the non-ECT group, which showed very steady improvement throughout the 6 months (P < 0.0001). Henceforth, a rapid improvement in the severity was found to be associated with the ECT group. Both the domains of QOL, i.e., SF-36 physical component summary and mental component summary were dependent on the severity of illness. Improvement in the severity led to a betterment in the QOL scores in all the patients. Conclusion: ECT along with psychotropic medications gives better results in terms of reducing the severity of the disease. Along with reducing the severity, it also helps the patient to achieve a better QOL.

Keywords: Efficacy, electroconvulsive therapy, quality of life


How to cite this article:
Kumar S, Saldanha D, Chaudhury S. Efficacy of electroconvulsive therapy and its impact on quality of life of patient: A longitudinal study. Med J DY Patil Vidyapeeth 2020;13:373-8

How to cite this URL:
Kumar S, Saldanha D, Chaudhury S. Efficacy of electroconvulsive therapy and its impact on quality of life of patient: A longitudinal study. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Dec 5];13:373-8. Available from: https://www.mjdrdypv.org/text.asp?2020/13/4/373/290167




  Introduction Top


Electroconvulsive therapy (ECT) is a neurostimulation intervention that involves the application of a mild electrical current in specific neurocortical areas for the purpose of inducing a therapeutic grand mal seizure. Despite the efforts to develop new and better psychotropic medication, 30%–50% of patients treated with antidepressants and 50% of patients treated with conventional antipsychotics were still medication refractory.[1],[2]

Further research and methodological advances led to renewed interest in the role of ECT. There are no absolute contraindications to ECT.[3]

ECT is considered a first-line treatment when medical or psychiatric factors require a rapid and robust clinical response. ECT poses less risk to a patient than medication (e.g., during pregnancy or in elderly patients), when there is a clear history of medication resistance or a history of favourable response to ECT, or when the patient prefers ECT to other psychotropic treatments. The clinical literature establishes the efficacy of ECT in specific neuropsychiatric disorders. There is substantial evidence about the safety and efficacy of ECT as a therapeutic modality in psychiatric disorders.[2]

Indian literature also shows increase in the number of researches regarding the use of ECT, which clearly indicates that ECT is emerging once again as a useful treatment in psychiatry. ECT is more widely used in India as compared to western countries. A study suggests that a combination of ECT and antipsychotic drugs give better results as compared to psychotropic drugs alone. In India still, ECT is primarily used for patients suffering from schizophrenia followed by major depression, mania, catatonia, and dysthymia. Due to lack of knowledge about ECT and misconceptions, patients and their relatives still consider ECT as a stigma but if they are properly informed about the doctors then this stigma attached to receiving ECT and the misconceptions will go away.[3],[4],[5],[6]

The prevalence of mental disorders (depression, anxiety, posttraumatic stress disorder, bipolar disorder, and schizophrenia) was 22.1%. Global burden of mental illness accounts for 32.4% of years lived with disability and 13·0% of the disability-adjusted life years.[7],[8]

The 12-month prevalence in the Asian and African regions was reported to be on the relatively lower side, varying between 3.3% and 7.4%. Nation mental health survey done in 2015–2016 suggests that mental morbidity is estimated to be 10.6%.[9],[10] A study shows that an overall lifetime prevalence of mental disorders in Pune is nearly 5%. The most common disorder was depression followed by substance use and panic disorders. Males were reported to be at a higher risk.[11],[12] The occurrence of a psychiatric disorders in a family member not only affects the individual, but also his educational, occupational, personal, and social life. In addition, the entire family also suffers from negative consequences. This has a direct bearing on the quality of life (QOL). Today, in clinical trials and health services research, QOL measures are often included to describe effects of treatments or of special ways of delivering treatments.[13],[14]

ECT decreases the morbidity in psychiatric illnesses, reduces drug requirement during maintenance, which leads to improvement in QOL in the domain of physical capacity, satisfaction with health and environment in a shorter duration of time. Research shows that ECT is associated with rapid and robust improvement in function and QOL. QOL and function are improved as early as 2 weeks after the completion of ECT.[15]

There is a paucity of Indian work in this area. Therefore, the present study was undertaken to evaluate and compare the efficacy of ECT and its impact on the QOL of patients suffering from affective disorders and schizophrenia, treated with ECT along with pharmacotherapy and patients treated with pharmacotherapy alone


  Materials and Methods Top


This prospective, longitudinal study was carried out from July 2014 to September 2016 at a tertiary care medical college hospital and research center. Institutional Ethical Committee clearance was obtained before starting the study (letter no. DPU/802 (36)/2014 dated 22/11/20140).

Sample

The study included 30 consecutive hospitalized patients suffering from affective disorder or schizophrenia and needing ECT and 30 other patients with the same diagnosis and severity, who refused to undergo ECT and opted for medication alone. Following inclusion and exclusion criteria's were followed in the conduct of the study.

Patients diagnosed to be suffering from affective disorder (F30, 31, 32) or schizophrenia (F20) by ICD 10 DCR and those who gave written and informed consent were included in the study.

Patients with age group below 18 years, suffering from intellectual disability, who have been treated with ECT before and those suffering from effects of any head injury were not taken as a sample for the study.

Following tools were used to assess the severity of the morbidity and the QOL of the patients.

The positive and negative syndrome scale (PANSS) is a popular scale to assess symptom severity in schizophrenia. This 30-item scale comprises a 7-item positive symptom subscale, a 7-item negative symptom subscale, and a 16-item general psychopathology subscale. The PANSS has demonstrated high internal reliability, good construct validity, and excellent sensitivity to change in both short-term and long-term trials The strengths of the PANSS include its structured interview, robust factor dimensions, reliability, the availability of detailed anchor points, and validity.[16]

The Beck's depression inventory (BDI-II) was used to assess the severity of depression. This instrument first proposed by Beck et al.[17] has been used in more than 7000 studies so far. The BDI has undergone two major revisions: In 1978 as the BDI-IA and in 1996 as the Beck Depression Inventory-II (BDI-II). The BDI-II assesses psychological and somatic manifestations of 2-week major depressive episodes. Unlike the original version, the BDI-II does not reflect any particular theory of depression.[18]

The short form-36 (SF-36) questionnaire was chosen for the purpose of the assessment of QOL in the study group. The SF-36 questionnaire is a tool that holistically assesses health-related QOL and adopts intervening methods to improve health-related QOL.[19]

Methodology

All the patients who participated in the study were adequately informed about the nature of the study and extent of involvement required in terms of time and sharing the details. All the patients included in the study gave written informed consent. Socio-demographic profiling was done. Pro forma containing all the relevant and detailed history of presenting illness, details of the past psychiatric illness, mental status examination along with a history of psychiatric illness in other family relatives were documented. The required tools were applied to assess the severity of the mental disorder as well as the QOL in the study group. Patients were given ECT under anesthesia thrice a week. A minimum of 6 ECT sessions were given to all the patients. The same tools were applied at 3 months and 6 months following the ECT.

Statistical analysis

Data analyses were performed using Statistical Package for the Social Sciences (SPSS Version 16) program (IBM, Chicago, IL. USA). Mann–Whitney test was used to compare data.


  Results Top


The basic socio-demographic details are illustrated in [Table 1]. There was no significant difference in the two groups in age, gender distribution, religion, domicile, education, occupation, and marital status. In the study group, 58 cases (96.7%) did not have any past psychiatrist history in the family while 2 subjects (3.3%) had a family history of psychiatric disorder. The study group shows a majority of cases, i.e., 33 (55%) were suffering from depression while 27 cases (45%) were suffering from schizophrenia.
Table 1: Demographic and clinical characteristics of the patients in the study

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On BDI-II 54.55% cases had a score in 36–40 range followed by 33.33% cases who had scores in 31–35 range, while only three cases had scores higher than 41. Mean score was 36.81. Hence, it is clear that the majority of the cases suffered from depression.

The study group shows that majority of the patients, i.e., 62.96% had PANSS score in 91–95 range followed by 33.33% in 86–90 range and 1 case had a score in between 96 and 100. The mean PANSS score was 90.81.

The BDI-II mean score at baseline was reduced from 36.60 to 17.80 in 3 months with a further improvement to 10.80 at 6 months. However, in the non-ECT group, the mean score was reduced from 37.0 to 30.94 at 3 months and further to 16.85 at 6 months.

The PANSS mean score at baseline was reduced from 90.20 to 42.80 in 3 months with a further improvement to 30.47 at 6 months. However, in the non-ECT group, the mean score was reduced from 91.58 to 64.92 at 3 months and further to 36.0 at 6 months.

The SF-36 physical component summary (PCS) mean score at baseline was increased from 12.65 to 95.87 in 3 months with a further improvement to 99.22 at 6 months. However, in the non-ECT group, the mean score was increased from 10.44 to 45.41 at 3 months and further to 93.22 at 6 months.

The SF-36 mental component summary (MCS) mean score at baseline was increased from 2.89 to 90.29 in 3 months with a further improvement to 99.06 at 6 months. However, in the non-ECT group, the mean score was increased from 0.41 to 38.52 at 3 months and further to 85.57 at 6 months.

Comparison of BDI-II, PANSS, SG-36PCS, and MCS score at baseline, 3 months, and 6 months after ECT in study group is shown in [Table 2], [Table 3], [Table 4], [Table 5], respectively.
Table 2: Comparison of Beckfs Depression Inventory-II score at baseline, 3 months, and 6 months according to electroconvulsive therapy in study group

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Table 3: Comparison of positive and negative syndrome scale score at baseline, 3 months, and 6 months according to electroconvulsive therapy in study group

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Table 4: Comparison of Short form-36 physical component summary score at baseline, 3 months, and 6 months according to electroconvulsive therapy in study group

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Table 5: Comparison of Short form-36 mental component summary score at baseline, 3 months, and 6 months according to electroconvulsive therapy in study group

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  Discussion Top


The study group shows a majority of cases, i.e., 33 (55%) were suffering from depression while 27 cases (45%) were suffering from schizophrenia. This can be explained by the higher prevalence of depression worldwide[20] and our country is no exception. Among the schizophrenia patients, the majority, i.e., 17 cases (62.96%) had PANSS score in 91–95 range followed by 9 cases (33.33%) in 86–90 range and 1 case had a score in between 96 and 100. The mean PANSS score was 90.81. These findings were similar to the study of Garg et al.[15] Majority of the cases had severe role limitation due to emotional problems while physical functioning domain was the least affected. This is similar to the study of Garg et al.[17] where the same domains were considered as the most and the least affected, respectively.

The results showed that in the ECT group every patient came for follow-up however, in the non-ECT group, there was a decline in the number of follow-up patients. The present study shows 100% turns up at 6 months' follow-up in the ECT group whereas there was only 72.22% turn up in the non-ECT group at the 6 months. The follow-up rates in the ECT group were higher than a similar prospective study done on QOL post-ECT where the follow-up rate was found to be only 60% as shown by McCall et al.[14]

Comparison of BDI-II score among patients, who underwent ECT with those who did not, showed that the ECT group had a rapid and robust reduction in the severity within 3 months after the admission. At 6 months, there was a decline in the severity but it was not as high as it was at 3 months. The improvement was still superior in the ECT group even at 6 months [Table 2]. This was similar to the results found in a comprehensive meta-analysis of the randomized controlled trials (carried out between 1956 and 2003) that revealed a significant superiority of the ECT in all comparisons: ECT versus placebo effect, ECT versus simulated ECT, ECT versus placebo, ECT versus antidepressants, ECT versus TCA, and ECT versus MAOIs.[21]

While comparing the PANSS scores among patients who underwent ECT with those who did not, it is evident that the ECT group showed a rapid and robust reduction in the severity within 3 months after the admission. At 6 months, there was a decline in the severity but it was not as high as it was at 3 months. The improvement was still superior in the ECT group even at 6 months [Table 3]. A study by Haskett and Loo[22] showed the same results, ECT in combination of antipsychotics gives a better result rather than antipsychotics alone. There was a 100% turns up at 6 months' follow-up in the ECT group whereas there was 75% turn up in the non-ECT group at the 6 months' follow-up.

Comparison of SF 36 PCS scores among patients who underwent ECT with those who did not show that the ECT group showed a rapid and robust improvement in PCS of SF 36 at 3 months after the admission. At 6 months, there was improvement not as high as it was at 3 months. The improvement was still superior in the ECT group even at 6 months [Table 4]. Comparison of SF 36 MCS score among patients, who underwent ECT with those who did not, showed that the ECT group had a rapid and robust improvement in MCS of SF 36 within 3 months after the admission. At 6 months, there was an improvement but was not as high as it was at 3 months. Between the two groups, ECT group showed a rapid improvement in SF 36 MCS scores as compared to the other group at 3 months. However, at 6 months, the difference in the improvement was not as remarkable as it was at 3 months. The improvement was still superior in the ECT group even at 6 months [Table 5]. This is similar to the findings of a study by Mushtaq et al.,[23-25] where mean well-being index of study group was 14 which was higher than control group at 11. These findings clearly indicates that ECT not only is efficacious as compared to medical treatment alone in reducing the severity of illness, but it also improves the QOL of the patient in a shorter duration of time which is very important for people suffering from mental disorders. It allows them to return to their normal routine life in a much shorter period as compared to the non-ECT group.

Limitation

The sample size was rather small due to paucity of time. A larger sample with longer follow-up would perhaps give a better picture of QOL among these patients who prefer treatment with ECT and antipsychotic drugs than antipsychotic medications alone.


  Conclusion Top


ECT along with psychotropic medications gives better results in terms of reducing the severity of the disease. The reduction in the severity is markedly seen at 3 months follow-up as compared to the non-ECT group followed by a steady continuation in the reduction of severity at 6 months as well. Along with reducing the severity, it also helps the patient to achieve a better QOL.

Future recommendations

A study with a larger sample and a long follow-up period would provide a better understanding about the effect of ECT on the QOL.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

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



 

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