Kids with concussion may recovery fast if they return to school within 2 days: study - Global News

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Guidance for diagnosing and managing migraine - News-Medical.Net

Migraine is a major cause of disability, affecting about 12% of people. A 2-part series published in CMAJ (Canadian Medical Association Journal) on diagnosing and managing the condition with both acute and preventive therapy provides guidance for clinicians. https://www.cmaj.ca/lookup/doi/10.1503/cmaj.211969.

"The goal of treatment of migraine attacks is to provide rapid relief from pain and other migraine-related symptoms, to restore patient function and to prevent recurrence," writes Dr. Tommy Chan, Department of Clinical Neurological Sciences, Western University, London, Ontario, with coauthors.

"A stratified approach to treatment that empowers patients to choose from different options, depending on attack symptoms and severity, and encourages them to combine medications from different classes (e.g., nonsteroidal anti-inflammatory drugs and triptans) for severe or prolonged attacks, is preferred."

Part 2 of the review, which will be published February 6, focuses on preventive treatment to reduce the frequency and severity of migraine attacks.

Canadian Medical Association Journal

Journal reference:

Tzankova, V., et al. (2023) Diagnosis and acute management of migraine. Canadian Medical Association Journal. doi.org/10.1503/cmaj.211969.

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COVID-19: Outbreak declared at Seaforth Community Hospital; WHO emergency declaration enters year 3 - Stratford Beacon-Herald

A COVID-19 outbreak at Seaforth Community Hospital has closed its inpatient unit to admissions until further notice, health-care officials have announced.

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A COVID-19 outbreak at Seaforth Community Hospital has closed its inpatient unit to admissions until further notice, health-care officials have announced.

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The Huron Perth Healthcare Alliance publicly reported the outbreak Saturday.

“Patients, family/caregivers and team members affected by the outbreak are in the process of being notified,” the hospital group said in a news release, adding that contact tracing and further tests are also underway.

With the exception of those in palliative care, visiting restrictions are in place. Families and caregivers will be made aware of opportunities for virtual connections, officials said.

Hospital outbreaks are declared when two or more COVID-19 cases that could have been acquired in the building are confirmed among patients or staff.

The outbreak in Seaforth was declared as the hospital’s emergency department was in the midst of a temporary reduction in service due to “sudden” human resource shortages. Seaforth’s emergency department resumed regular hours of operation Monday morning.

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According to Public Health Ontario data last updated on Jan. 21, there are two other active COVID-19 outbreaks in Huron and Perth counties, both in long-term care homes.

Two people in the region have died due to COVID-19 so far this year, public health figures show – one reported Jan. 10 and the other reported Jan. 15.

Exactly three years after declaring COVID-19 a public health emergency, the World Health Organization decided Monday not to lift that designation.

Tedros Adhanom Ghebreyesus, the director-general of the international body, said “there is no doubt that we’re in a far better situation now” than a year ago, when the highly transmissible Omicron variant was at its peak. But Tedros warned that in the last eight weeks at least 170,000 people have died around the world in connection with the SARS-CoV-2 virus. He called for at-risk groups to be fully vaccinated, an increase in testing and early use of antivirals, an expansion of lab networks, and a fight against “misinformation” about the pandemic.

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“We remain hopeful that in the coming year, the world will transition to a new phase in which we reduce hospitalizations and deaths to the lowest possible level,” he said.

About 540 people in Ontario have died due to complications related to COVID-19 over the same time period, Public Health Ontario data show. As of Jan. 21, there were 250 active outbreaks in the province – 103 long-term care homes, 79 retirement homes, 37 hospitals, and 31 other congregate-living settings.

Canada’s chief public health officer, Dr. Theresa Tam, said no matter what the WHO decided, Canada would continue to track cases, serious illnesses and deaths, as well as roll out vaccination campaigns. Cases, hospitalizations and deaths associated with the virus spiked noticeably over Christmas and in early January, Tam said, but all now appear to be trending down.

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“We mustn’t, I think, let go of the gains that we’ve had in the last several years,” she said. “I think whatever the decision is made by the director-general of WHO, I think we just need to keep going with what we’re doing now.”

Ontario is through the worst of the respiratory virus season, with the three major viral threats on the decline, though a more transmissible variant of COVID-19 may lead to a “smaller” spring wave, the province’s top doctor said Thursday.

Chief medical officer of health Dr. Kieran Moore “strongly” recommended people wear masks in indoor public settings in mid-November, as the flu, respiratory syncytial virus and COVID-19 were circulating and straining children’s hospital capacity.

Moore said at the time that a renewed mask mandate was on the table, but now with the province on the other side of a tough respiratory season after three years of a pandemic, that may be off for good.

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“I really can’t see us considering that,” he told the Canadian Press. “In no jurisdiction has there been a mandatory masking recommendation, nor has our expert panel recommended that to us. So we hope the highest-risk Ontarians will continue to take the layers of protection seriously.”

Moore said that includes staying at home when sick, practising good hand hygiene and “cough etiquette,” and the strong recommendation for indoor masking continues. As well, he recommends people stay up-to-date on COVID-19 booster shots, particularly people more susceptible to the virus.

The flu in Ontario peaked in early December, with around 568 patients in hospital, and now that number is 80, Moore said. RSV peaked at the same time, with about 350 people in hospital.

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“We’re now down to 190, so that number is slowly going down with RSV,” Moore said. “RSV typically doesn’t have that high peak that influenza does, and stays with us throughout the winter months, but its impact is decreasing significantly week by week.”

The COVID-19 situation has also been improving, Moore said, with 99 people in ICU, the lowest number since July.

However, previous pandemic years have seen spring waves of COVID-19, so Moore said he is closely monitoring the more transmissible XBB variant.

“This virus has tended to have 90- to 100-day cycles in its mutations, and each subsequent variant has been more infectious,” he said, “so we do anticipate having another, smaller wave.”

-With files from the Canadian Press

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COVID-19: Outbreak declared at Seaforth Community Hospital; WHO emergency declaration enters year 3 - Stratford Beacon-Herald
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Review | Three artists blow away the winter blues at Earls Court Gallery - Hamilton Spectator

Brenda Nieves says she fell for clay the moment she touched it.

That was 10 years ago. A friend had encouraged Nieves to take an art course at Toronto’s Central Technical School.

“To ease the tension and stress I was experiencing having a fragile child,” Nieves tells me. “I thought I was going to be painting, a hobby I loved as a child. I loved sculpture: wood, clay, metal. With clay though, there was a visceral response to the touch. I had to do more.”

Since then she has created an impressive body of work — and teaches at the school where her love of clay took off.

Nieves joins Diana Rosa and Mimmo Baronello in “View Life,” a winter-blues-busting exhibition at Earls Court Gallery.

Nieves embraces both functional and sculptural ceramics. In her teaching she focuses on skills needed for functional work, because these skills are the same as those used for ceramic sculptures.

“Sculpture is my passion but when I am procrastinating, throwing a functional piece is just what I need to get me going.” In this exhibition she is showing what she calls her mythical sculptures. She hand-builds these hollow, almost life-size busts from stoneware, often adding unexpected materials such as cloth and wood.

“I do a lot of experimenting with texture, techniques, glazing. I love to think of ways to have the clay show different aspects of emotions and energy, delicacy or strength.”

“The Keeper” is loaded with visual and tactile appeal. Twisted rings encircle the horns at the root. Hair consists of curly shapes which frame the face and fall onto the shoulder. Face, neck and shoulder reveal contrastingly smoother surfaces. The base is made from folded cloth. One eye is closed, the other open — a suggestion of inner and outer vision.

“One sculpture leads to another,” Nieves says. “Thoughts of how I am going to execute each sculpture start my thoughts of the next sculpture I want to try.”

“Medusa” taps into the ancient goddess who turned men into stone. Needless to say, she became the evil woman in patriarchal societies. Nieves says Medusa incorporates strength, power — and vulnerability.

Medusa’s hair is one gorgeous mess of energetic snakes with open mouths, proof of Nieves’s awesome technical expertise.

“Gaya’s Gift” pays tribute to an earth goddess with a head of leaf-like hair. The sculpture rests on small birch logs.

Nieves says she wanted “to challenge the viewer to reconcile the beauty of the figure with her state. In popular culture, beauty is synonymous with perfection,” she says. “Persons who are different or differently abled are often seen and judged within that context. I watched my beautiful, brilliant, courageous child deal with these perceptions every day. Gaya’s Gift is to help us view beauty on its own terms. ”

Rosa, too, deals with themes of beauty. An award-winning artist, she has been exhibiting locally and internationally for more than 15 years.

“I value the spontaneous approach and instincts to guide my hand,” she says. “My work starts with a number of sketches on paper. Sometimes I don’t paint, I just dedicate days to draw and move my hand creating shapes and magical places.”

She gravitates in her paintings to the human figure, using line to build up complex patterns and fantastical figures. In “Let it Bloom,” a well dressed couple sit facing each other. In placing them against a plain background, Rosa creates an ambiguous space. “My work is based on my dreams and humans’ emotions.”

This painting is about inner beauty, she says. “It’s the contrast between fashion and makeup and the possibilities of flowering, blooming and growing internally. The fruits and flowers are the accumulated information, history and everything within the heart, mind and soul.”

Baronello’s paintings are more lifelike in style. Yet his compositions, inhabited by humans, animals or birds, are also fanciful. In “Bulb of Life” he replaces iris bulbs with light bulbs, uniting bulbs, stems and purple blooms in a joyful tangle.

RH

Regina Haggo, art historian, public speaker, curator, YouTube video maker and former professor at the University of Canterbury in New Zealand.

View Life

Who: Brenda Nieves, Diana Rosa, Mimmo Baronello

Where: Earls Court Gallery, 215 Ottawa St. N.

When: until Feb. 18

Hours: 10 to 5 Tuesday to Friday, 10 to 4 Saturday

Phone: 905-527-6685

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BNT162b2 vax prevents delta, omicron infection in adolescents; benefits upped with booster dose | Latest news for Doctors, Nurses and Pharmacists | Respirology - MIMS

Roshini Claire Anthony

an hour ago

Full vaccination with the SARS-CoV-2 BNT162b2 vaccine reduced infection and hospitalization due to the delta and omicron variants of the SARS-CoV-2 infection, with an added benefit against the omicron variant in individuals who received a booster dose, according to a national study of Singaporean adolescents.

Using national databases, the researchers included 249,763 adolescents aged 12–17 years (median age 15 years, 49 percent female) in Singapore who received the BNT162b2 vaccine between September 1 and December 15, 2021 (delta variant wave) and between January 21 and April 28, 2022 (omicron variant wave). All individuals who presented to healthcare facilities with symptoms of SARS-CoV-2 infection during the same time periods were tested and individuals with confirmed infections (by PCR or antigen rapid testing), among those without prior SARS-CoV-2 infection, were included.

The total cohort contributed >56.2 million person-days of observation. Of the group, 76.1 percent were fully vaccinated (defined as 8 days following receipt of the second vaccine dose), 16.7 percent had received a booster dose, and 5.2 percent were unvaccinated. Of the 49,921 individuals who developed COVID-19, 0.7 percent were admitted to hospital.

Compared with unvaccinated individuals, individuals who were fully vaccinated documented 66 and 25 percent vaccine effectiveness against infection with the delta and omicron variants of the SARS-CoV-2 virus, respectively*. [Lancet Infect Dis 2022;doi:10.1016/S1473-3099(22)00573-4]

Vaccine effectiveness against hospitalization due to infections with the delta or omicron variants was 83 and 75 percent, respectively, in those who were fully vaccinated vs unvaccinated.  

Vaccine effectiveness against infection and hospitalization due to the omicron variant was further increased in individuals who received a booster dose of the vaccine (8 days after receiving a third dose) compared with unvaccinated individuals (56 and 94 percent, respectively).

Vaccine effectiveness against infection in fully vaccinated individuals waned over time, both for the delta variant (from 75 percent following completion of the second dose to 57 percent at 150–179 days) and omicron variant (from 47 percent to 16 percent). Booster doses first increased the effectiveness of the vaccine against infection from omicron (60 percent 14–29 days after the third dose), before waning (40 percent after 60 days).

In contrast, vaccine effectiveness against hospitalization among fully vaccinated individuals remained stable over time, for hospitalization related to the delta variant (76–89 percent from 8–149 days after the second vaccine dose) and omicron variant (59–89 percent from 8–239 days after the second vaccine dose), and increasing following booster vaccination (84–96 percent against omicron-related hospitalization up to 60 days post-third dose).

There were no incidents of reinfection during the study period.

“Our findings add to the existing body of evidence showing that primary series vaccine effectiveness against SARS-CoV-2 infection was lower for omicron than for delta, and gradually waned over time for both variants,” said the authors.

Booster benefits highlighted

“[W]e showed that a booster dose provided the greatest protection against both infection and hospitalization,” said the authors. “Specifically for omicron, the booster increased protection against hospitalization to levels similar to those against delta after the primary series.”

“These findings highlight the usefulness of the booster dose in reducing stress on healthcare systems and maintaining individual protection against severe disease in an omicron-dominated wave,” they concluded, calling for further research into identifying the long-term waning of booster dose effectiveness.

They acknowledged that lack of information on certain comorbidities may have affected the findings. Additionally, hospitalization, being a clinical decision, is a “subjective measure of disease severity.” A lack of routine genomic testing also meant that variant type was subject to assumption based on the local infection wave.

*following adjustment for age, gender, ethnicity, socioeconomic status, and daily infection rate

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BNT162b2 vax prevents delta, omicron infection in adolescents; benefits upped with booster dose | Latest news for Doctors, Nurses and Pharmacists | Respirology - MIMS
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COVID-19 outbreak declared at Seaforth Community Hospital - My Stratford Now

A COVID-19 outbreak has been declared at the Seaforth Community Hospital.

Huron Perth Healthcare Alliance officials say it’s in the hospital’s Inpatient Unit which is now closed to admissions until further notice.

Outbreak status refers to two or more confirmed positive COVID-19 cases among patients or team members that could have possibly been acquired in the hospital.

HPHA is working with Huron Perth Public Health and patents, family/caregivers and team members impacted by the outbreak are being notified with necessary contact tracing
taking place.

Family and caregiver pesence on the unit has been restricted with the only exception is for palliative patients at end of life.

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Many good health reasons to eat an apple every day - Delta Optimist

Apples are one of the oldest cultivated fruit, dating back at least 6,500 years, and have some of the greatest health benefits.  There is truth behind the old adage “An apple a day keeps the doctor away.”

They are high in soluble fibre, low calorie, low on the glycemic index, and contain beneficial vitamins like Vitamin C, quercetin, pectin and potassium. They are a good antioxidant (especially the peel) and are the number one fruit to help prevent diabetes, cancer and heart disease. They help lower cholesterol as the soluble fibre in apples binds with saturated fat (preventing it from entering the bloodstream). 

To aid weight loss, it is beneficial to eat an apple prior to a meal, as they curb your appetite. Apples encourage more saliva production, which protects your teeth. Some studies show mental health benefits of increased intellectual capabilities and a slowing down of mental aging and Parkinson’s (due to their antioxidant properties). The fibre and quercetin (a plant polyphenol) builds immunity to combat virus and bacteria, especially when one is stressed. The antioxidant properties help regulate ocular muscles and nerves, helping to preserve one’s eyesight.

Apples also speed up liver regeneration. The pectin in apples binds with heavy metals in the gut (aluminum and lead) and helps eliminate them. Heavy metal poisoning is one of the leading causes of Alzheimer’s disease.  Apples are also proven to reduce anxiety when eaten regularly. The soluble fibre pectin aids IBS symptoms and ulcerative colitis.

Apple cider vinegar (fermented apple juice) has become a health rage and has its own set of health benefits including aiding digestion and weight loss, lowering inflammation and boosting energy.

Consuming it before a meal is said to help reduce blood sugar spikes afterward. It also helps with the absorption of the following nutrients: protein, calcium, iron, carbohydrates, fats, Vitamins A,B,C and E and magnesium.  Apple cider vinegar is an antifungal, antibacterial and antiviral helps with absorption of calcium and other minerals. Even though it is acidic, once absorbed in the gut it is slightly alkaline.  As it is acidic before digestion, it shouldn’t sit on the teeth as it may soften enamel. It is best to drink apple cider vinegar through a straw or rinse your mouth out afterwards with water.

These are some (proven and unproven) folk remedies using apple cider vinegar. Here are several but not all: removes age spots, as a soak for arthritic hands and feet or for athlete’s foot, soften foot corns, prevents asthma, heals bruises, fights cancer, helps prevent cataracts, eliminates cold sores, soothes a sore throat, eliminates cramping, treats dandruff, lowers blood sugars, kills diarrhea causing bacteria, soothes eczema and itching due to rashes, bites or stings, eliminates fatigue, increases stomach acid for those with gallbladder issues (associated with low stomach acid), aids hay fever, reduces headaches, dissolves the glue that holds nits (head lice eggs) onto the hair, treats hiccups, lowers blood pressure, aids osteoporosis by aiding calcium absorption, stops nose bleeds, aids absorption of all vitamins and minerals, treats smelly feet and warts.   

As with any alternative remedy, it is important to talk to your naturopath and doctor beforehand to make sure there are no contra-indications with existing medicines, but there doesn’t seem to be any doubt that apples and apple cider vinegar contribute to healthy living.  There are also many beauty aids but space prevents me from covering them in this article.

I personally use apple cider vinegar in a wonderful salad dressing with our Lemon-Honey Elixir, crushed garlic, avocado oil and a pinch of dried mustard. 

Claire Nielsen is a health coach, author, public speaker and founder of www.elixirforlife.ca. The information provided in the above article is for educational purposes only and is not a substitute for professional health and medical advice. Please consult a doctor or healthcare provider if you're seeking medical advice, diagnoses and/or treatment.

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'Sharp upswing': Flu shots encouraged after early peak of Alberta cases, says U of A infectious disease specialist - Edmonton Journal

"The peak was amongst the highest that we've had since 2009 and it was a really sharp upswing and then are fairly sharp drop as well."

A nurse gives a patient a flu shot at East Edmonton Health Centre in Edmonton. Photo by Ian Kucerak /Postmedia

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Despite an earlier-than-usual peak in Alberta’s influenza season, Albertans who have not yet gotten the jab are encouraged to get their flu shot.

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Dr. Lynora Saxinger, an infectious disease specialist at the University of Alberta, said the current flu season has been a “peculiar” one, with a very rapid and aggressive start.

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“The peak was amongst the highest that we’ve had since 2009 and it was a really sharp upswing and then a fairly sharp drop as well,” she said.

“Then, of course, the season was getting rolling pretty early on. Also in that time period of vaccination, usually there’s a little bit more lead time from having vaccines available to having the peak.”

Typically, flu cases peaks in late December but this season it reached the highest point in the third week of November. Last year also saw an unusual “mini peak” of flu cases in May.

“The entire pattern of what we generally see shifted a fair amount this year, and so it kind of leaves an open question as to what might happen for the rest of the season,” she said.

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According to the latest provincial data, there have been 8,643 cases of influenza recorded so far in the 2022-23 season — 8,593 were influenza A, and 50 were influenza B.

“The overall pattern is often there’s a later season influenza peak and it’s often influenza B and so I’m quite curious to see if we’re going to actually see an influenza B presence now because we have seen barely any influenza B since essentially the end of 2019,” Saxinger said.

There could be a number of factors behind the rapid start to the flu season.

“If you have a light year of respiratory virus you often have a heavier year, the next year,” Saxinger said. “The reason for that is if you think about partial immunity within a community caused by some circulation of a virus, there’s just a higher level of susceptibility after a lighter year.

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“Basically a lot of these viruses took an extended holiday during COVID. There just was much less exposure to a lot of these things.”

The numbers also depend on the amount of testing in a given year.

1. 

   Edmonton research measures 'insidious' impact of stigma for COVID long-haulers

2. 

   Four-year-old child among first reported influenza deaths in Alberta

“This past fall peak, they were testing probably six to 7,000 isolates and in previous years they were testing 1,400 isolates,” Saxinger said. “There was a lot more testing of respiratory viruses going on with this last peak too. It’s hard to know whether it’s really worse, but it certainly was more tested.”

Hospitalizations, deaths higher

Hospitalization numbers from influenza are also higher than in previous years. To date, there have been 1,979 hospitalizations, 205 admissions to the ICU and 102 deaths.

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This is compared to the 2019-2020 season when 1,534 hospitalizations and 39 deaths were recorded.

“Certainly every single year there’s a bunch of severe flu cases in the hospital and in the ICU and in this case that was happening earlier than it generally does,” Saxinger said.

She encourages people who have not had their flu shot yet to do so.

“The pattern is definitely not as predictable as some years have been,” Saxinger said. “There is, I think, probably a higher risk of another influenza B surge than an influenza A surge … We haven’t seen a sign of that yet, but the current vaccine would have some protection against influenza B and influenza B basically can be as severe as influenza A.”

Albertans can also get their COVID-19 booster at the same time.

“There’s no problem with giving them at the same time. Your immune system can handle that perfectly well,” Saxinger said.

“Giving them at the same time, I think, potentially would be a really great way forward if we’re going to be getting seasonal boosters around the same time because we suspect that COVID will also be a fall/winter predominant virus.”

ajunker@postmedia.com

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Cognitive function during ECT in young adults with TRD | NDT - Dove Medical Press

Introduction

Depressive disorder is common, debilitating, and significantly impacts the quality of life of affected individuals.^1,2 There have been many studies on depression in children, adolescents and the elderly^3–8 but relatively few in young adults,^9–11 despite them having different social and neurobiological profiles.^12,13 Almost 40% of patients experience their first episode of depression before 20 years of age.² Their clinical course tends to fluctuate, with multiple recurrences in the context of life transitions.¹²

Depressive disorder that does not respond satisfactorily to treatment is referred to as treatment-resistant depression (TRD).¹⁴ Although TRD episodes are most commonly associated with major depressive disorder, they are also seen in the depressed phase of bipolar disorder;¹⁵ indeed, responses are not sustained in over 30% of individuals receiving treatment for unipolar depression (UPD) or bipolar depression (BPD).^16–18 TRD is therefore a significant public health problem characterized by extensive disability, increased suicide attempts, and higher medical costs.^16,19

Electroconvulsive therapy (ECT) has been used in clinical practice for over 80 years and is widely considered the most reliable therapy for TRD.^20–22 ECT is associated with a reduced risk of suicide in the year after discharge.²³ While there is strong evidence supporting the efficacy of ECT in middle-aged and older adults,^24,25 little is known about its efficacy and cognitive side-effects in younger adults (aged 18–30) with TRD. Previous studies have suggested that ECT in young adults improves clinical outcomes during the acute treatment phase.^26,27 Since TRD and non-TRD may differ clinically and biologically,^28,29 it still needs to be clarified whether young adult with TRD adequately respond to ECT, and the side-effects and prognosis require characterization.

This study therefore had the primary objective of establishing the clinical effectiveness, speed of response, and cognitive outcomes of ECT in young adult patients with TRD. The exploratory objective was to investigate differences in ECT responses in young adults with UPD and BPD. To better answer the primary objective, we used repeated evaluation after each ECT to detail the changes in depressive symptoms and cognitive function during the entire ECT process.

Materials and Methods

This longitudinal observational trial was conducted at Renmin Hospital of Wuhan University (Mental Health Center of Hubei Province, Wuhan, Hubei, China) in accordance with the Declaration of Helsinki (revised edition, 2013).³⁰ The Human Ethics Committee of Renmin Hospital of Wuhan University approved the study protocol. Patients or their legal guardians provided informed consent and could withdraw from the trial at any time for any reason. This report follows the STROBE statement.³¹

Trial Design

We recruited 41 patients to Cohort 1, the “main” cohort. Routine symptom and detailed cognitive function examinations were performed at baseline, after the entire ECT course, and one month later. To map the detailed trajectory of symptoms and subjective memory impairment (SMI) during ECT treatment, depressive symptom and SMI evaluations were performed after each ECT session.

Cohort 2 was used to detect changes in objective memory function with ECT and represented a 23-patient subset of Cohort 1. The forward digital span test (FDST),³² a simple and widely used tool of verbal short-term and working memory, was assessed after each ECT session. Considering potential practice effects, we recruited 15 healthy controls (HCs) matched for age, sex, and years of education, who received twelve FDSTs at the same test frequency (three times per week) as a longitudinal benchmark. Figure 1 shows the trial flow chart and study design.

Figure 1 Study flow chart. Abbreviations: TRD, treatment-resistant depression; UPD, unipolar depression; BPD, bipolar depression; HC, healthy control; ECT, electroconvulsive therapy; MADRS, Montgomery-Äsberg Depression Rating Scale; HAMA, Hamilton Anxiety Rating Scale; RBANS, Repeatable Battery for the Assessment of Neuropsychological Status.

Participants and Inclusion and Exclusion Criteria

Sixty-two inpatients were recruited from March 1st, 2021 to January 31st, 2022. The inclusion criteria were (1) participants aged between 18 and 30 years; (2) ability to provide informed consent; (3) meeting ICD-10³³ criteria for the diagnosis of major depression or bipolar disorder current episode depressive, with or without psychotic features (F31.3, F31.4, F31.5, F32, F33) using the Mini International Neuropsychiatric Interview (MINI);³⁴ (4) meeting the definition of TRD: patients with UPD required a minimum of two prior treatment failures and confirmation of prior adequate dose and duration,¹⁵ while patients with BPD required no response to treatment after 12 weeks of treatment or a well-documented failure to respond to at least two trials of antidepressants or an antidepressant and a mood stabilizer;³⁵ and (5) scored ≥20 on the Montgomery-Äsberg Depression Rating Scale (MADRS).³⁶ We excluded patients if they: (1) failed to respond to earlier ECT; (2) had received ECT over the previous three months; (3) patients with manic episodes and mixed characteristics of BPD or scored ≥6 on the Young Manic Rating‎ Scale (YMRS);³⁷ (4) had a lifetime diagnosis of unstable, serious comorbidities or a history of epilepsy; (5) were pregnant or women without adequate contraception; and (6) were in other clinical studies or were unsuitable for participation as assessed by the investigators.

Age-, sex-, and education-matched HCs were recruited through advertisements. They were required to be in good physical health with no personal or first-degree family history of a psychiatric disorder, significant medical illness, psychotropic medication use, or use of other medications that could interfere with neuropsychological function.

ECT Procedures

All participants received a standard pre-ECT clinical assessment including a full physical examination, laboratory analyses, electrocardiogram, electroencephalogram (EEG), and monitoring for any risks or contraindications to anesthesia and/or ECT. All individuals included in the trial did not have any clinically significant abnormalities on this assessment. Patients received bitemporal electrode placement ECT which was performed three times per week using a Thymatron IV device (Somatics, LLC). Seizure threshold was determined at the first ECT session starting at a dose level of 50mC (or 10% of machine energy) and titrated upwards till a seizure of at least 15s was induced. Subsequent ECT treatments were administered at 1.5 times seizure threshold (or one level higher).³⁸ General anesthesia was induced with propofol (about 2 mg/kg) and myorelaxation with succinylcholine (about 1 mg/kg) and atropine (0.5 mg) before each session. Doses of propofol and succinylcholine were adjusted as needed in subsequent sessions. Orientation recovery tests after each ECT session were used to measure recovery. The decision to discontinue ECT was made by the patient’s psychiatrist after considering 1) reduced potential benefit of ECT; 2) side effects; 3) completed 12 ECT sessions; 4) patient preference; and 5) other medical considerations.

Pharmacotherapy

Individualized pharmacological regimens were determined by the patients’ psychiatrists. Patients maintained their previously prescribed antidepressants and antipsychotics during the trial. Anticonvulsant drugs, mood stabilizers, and benzodiazepines were discontinued during the entire course of ECT. Single-dose short half-life benzodiazepines were used as necessary when patients became agitated or felt anxious. When patients suffered from insomnia, nonbenzodiazepines were temporarily prescribed.

Measurement Tools and Visit Schedule

Efficacy Measures

The MADRS was used to evaluate depressive symptoms and was performed at baseline, after each ECT session, and at one-month follow-up. A response was defined as a decrease in total MADRS score >50% from baseline to the end of treatment, and remission was defined as a total MADRS score <10 at the end of the treatment.³⁹ The MADRS was also divided into four factors: 1) cognitive-pessimism; 2) affective; 3) cognitive-anxiety; and 4) vegetative.⁴⁰ The Hamilton Anxiety Rating Scale (HAMA)⁴¹ was used to evaluate the anti-anxiety effect of ECT and was performed at baseline, after the course of ECT, and at one-month follow-up. The HAMA was also divided into somatic anxiety and psychic anxiety.

Safety Measures

Any adverse events (AEs)/serious AEs (SAEs) or patients who dropped out for any reason were recorded.

Cognitive Measures

In Cohort 1, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)⁴² was performed at baseline, after the course of ECT, and at one-month follow-up to assess objective cognitive function. SMI was assessed with the cognitive component of the Columbia Subjective Side Effects Schedule (CSSES)⁴³ after each ECT: “have you had memory problems since ECT?” This item was scored on a 4-point Likert-type scale where 0 = none, 1 = mild, 2 = moderate, and 3 = severe.

Objective memory function changes were assessed in Cohort 2. Given that most cognitive tests are complex and can take a long time to perform, tests should be simple and reliable to perform. Therefore, the FDST was chosen to evaluate memory function after each ECT session. Twelve FDSTs were performed on HCs at the same test frequency (three times per week) to provide a longitudinal benchmark.

All assessments in patients were administered 24 hours after every ECT session to avoid possible acute treatment effects.

Sample Size

The sample size was calculated using G*Power software (ver. 3.1.9.7).⁴⁴ We expected to detect a moderate effect size (Cohen’s f = 0.25) of MADRS in seven visits (the mean number of ECT treatment is approximately six plus a baseline visit) with a power of 0.85, α of 0.05 (two-sided), and obtained a sample size of 42.

Statistical Methods

Missing Data

Longitudinal analyses did not require input of missing values, because the statistical methods (mixed model for repeated measures (MMRM) and cumulative link mixed model for repeated ordinal outcomes (CLMM)) could accommodate missing data.

Descriptive Analyses

For baseline comparisons, continuous demographic and clinical characteristics were compared using Welch’s two-sample t-test, and categorical characteristics were analyzed using Fisher’s exact test.

Efficacy Analyses

The primary outcome was the change in MADRS at post-treatment visit from baseline. Secondary outcomes were changes in the MADRS subscales, HAMA and its subscales. MMRM analyses were performed to estimate the dynamics of these continuous outcomes and compare the between-subgroup differences between the UPD and BPD subgroups. In general, the MMRM model included subgroup, visit (as a categorical variable), and the subgroup*visit interaction as fixed factors. Baseline values, fluoxetine, and chlorpromazine equivalent dose were included as covariates to control for potential bias from baseline status and the effect of pharmacotherapy. An unstructured covariance matrix will be used to model the within-subject correlation, and the Kenward-Roger approximation method was used to calculate the denominator degrees of freedom. Treatment effects were reported using MMRM least squares (LS) means and associated 95% confidence intervals (95% Cis). Pair-wise comparisons were adjusted using Tukey’s method.

Cognitive Analyses

For RBANS and FDST, similar MMRM analyses were also performed. As SMI was an ordinal variable, CLMM was performed, subgroup, visit, and the subgroup*visit interaction as included as fixed factors, and odds ratios (Ors) and their 95% Cis were used to examine whether the change in SMI increased with ECT treatment. Age, charge, and pulse width^45,46 were included as covariates in both MMRM and CLMM to control for potential confounders.

Statistical Software

All statistical tests were carried out using R version 4.1.0 (R Project for Statistical Computing) within RStudio version 1.4.1106 (RStudio) for Windows. LmerTest package⁴⁷ was used for MMRM analyses, ordinal package⁴⁸ was used for CLMM, effectsize package⁴⁹ was used to calculate the effect sizes, and ggplot2 package⁵⁰ was used for visualization.

Results

Participant Flow and Characteristics

Figure 1 shows the participant flow. For the main cohort, 62 patients were enrolled: 20 screen failures were excluded after entry, and 42 patients completed the visits after ECT treatment. Unfortunately, one patient withdrew informed consent after the trial completed; as a result, the final sample size for analysis was 41. Twenty-three patients also participated in Cohort 2. Descriptive data are presented in Table 1, and Table S1 presents the comparisons between the UPD and BPD subgroups.

Table 1 Descriptive Data of Included Subjects

Forty-one participants received a total of 272 ECTs, and 31 (75.6%) completed the one-month follow-up visit. Six patients ended ECT without a clinical response and less than 12 treatments due to fever, headache, and dissatisfaction with the efficacy. Ten patients dropped out at one-month follow-up. There were no significant differences in response/remission rates at the post-ECT visit between completers and dropout patients (see Table S2).

Efficacy Results

The LS mean change in total MADRS score from baseline to the end of treatment was −24.9 (95% CI = −27.9, −21.9), Cohen’s f = 1.19 (90% CI = 1.02, 1.31). Thirty-five (85.4%) and 12 (29.3%) patients met the criteria for response and remission after ECT. In subgroup analyses, the difference in response rate and remission rate between patients with UPD (80.0% and 28.0%) and BPD (93.8% and 31.3%) were non-significant (Fisher’s exact test, p = 0.376 and 1.000). Anxiety mirrored the depressive symptoms. In subgroup analyses, the antidepressant and anti-anxiety effects of CBT were similar. The reduction in total MADRS total score and its two subscales (cognitive pessimism and affective) and the HAMA subscale (somatic anxiety) were slightly but significantly larger in the UPD subgroup than the BPD subgroup at the follow-up visit (all adjusted P-values (Tukey’s method) <0.05, see Table S3). However, BPD patients received significantly more ECT sessions than the UPD patients.

At one-month follow-up, 16/31 (51.6%) and 8/31 (25.8%) patients met the criteria for response and remission. In subgroup analyses, the differences in response rates and remission rates between patients with UPD (57.9% and 36.8%) and BPD (41.7% and 8.3%) were not significant (Fisher’s exact test, p = 0.473 and 0.199). Details of the MADRS, HAMA, and their subscale estimates are presented in Table 2, Figure 2, and Figures S1 and S2.

Table 2 Estimated Least Squares Mean Effect Size of MADRS and HAMA Based on MMRM

Figure 2 MADRS and HAMA at baseline, post-ECT, and at follow-up. (A) Total Montgomery-Äsberg Depression Rating Scale (MADRS) score and (B) total Hamilton Anxiety Rating Scale (HAMA) score of Cohort 1 at baseline, post electroconvulsive therapy (ECT), and at follow-up. The pairwise comparisons between the three visits are all statistically significant (details are shown in Table 2). Abbreviations: UPD, unipolar depression; BPD, bipolar depression.

As shown in Figure 3, Table S3, and Figure S3, the effect size of MADRS trajectories over the course of ECT was large. There were steep trajectories for MADRS and its four subscales after 3–4 ECTs, and the reduction from baseline was statistically significant after the first ECT. In subgroup analyses, the MADRS trajectories for both UPD and BPD patients were similar, except for the “vegetative” subscale, whose reduction in the UPD subgroup was significantly quicker than in the BPD group at visits 2–6 (adjusted p-values (Tukey’s method) <0.05, see Table S3).

Figure 3 Trajectory of MADRS. The Montgomery-Äsberg depression rating scale (MADRS) total score trajectory during the course of electroconvulsive therapy (ECT) treatment in Cohort 1. The reductions in total MADRS scores at each post-ECT visit from baseline are all statistically significant, but the between-subgroup differences (unipolar depression (UDP) versus bipolar depression (BPD)) were not significant (see Table S4).

Cognitive Results

As shown in Table 3 and Figure 4, at the post-ECT visit, there were no significant changes in total RBANS score nor the visuospatial/constructional, language, and attention subscales. There was a significant post-ECT increase in two RBANS subscales (immediate memory and delayed memory). At one-month follow-up, there was a significant increase in total RBANS score and the immediate memory, attention, and delayed memory subscales. Subgroup analysis suggested that the UPD subgroup contributed most to these changes, but the between-subgroup differences were not statistically significant after correction.

Table 3 Estimated Least Squares Mean Effect Size of RBANS Based on MMRM

Figure 4 RBANS at baseline, post-ECT, and at follow-up. (A) Total Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) score and (B–F) RBANS subscales for Cohort 1 at baseline, post electroconvulsive therapy (ECT), and at follow-up (details are shown in Table 3).

For SMI, 34 patients reported varying degrees of subjective cognitive impairment at different visits, and 19 patients reported persistent SMI at the follow-up visit. In the CLMM analysis, SMI significantly increased during ECT (OR = 3.20 (95% CI = 2.38, 4.28; Z = 7.817, p < 0.001)).

With respect to the trajectory of objective memory function during ECT, as there was a significant practice effect of FDST in the HC group, we focused not only on the within-group change but also the interaction effect size between groups. As shown in Figure 5, Figure S4, and Tables S5 and S6, the between-group differences were non-significant at most visits, except for visits 7 and 11. However, in subgroup analyses, the between-subgroup differences were non-significant after correction.

Figure 5 Trajectory of FDST. The Digital Span Test (FDST) trajectory during electroconvulsive therapy (ECT) treatment in Cohort 2. The between-group differences are non-significant at most visits, except for visits 7 and 11 (see Tables S5 and S6).

Safety Results

No SAEs occurred during the trial. One hundred and ten common AEs were recorded, with the top AEs being headaches (61 events), muscle aches (28 events), and nausea (7 events).

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Discussion

This is the first trial presenting detailed observations of the efficacy, speed of response, and cognitive changes of ECT in young adults with TRD. Our trial had two main findings. First, the effect size of ECT was large, with 85.4% of patients with TRD responding to an acute course of ECT and the largest improvements occurring during the first 3–4 ECT sessions. Second, there was a discrepancy between subjective and objective cognitive outcomes during ECT, with patients presenting with more subjective than objective cognitive adverse effects of ECT.

Efficacy

The severity of depression and anxiety was clinically and statistically reduced after ECT. These results were consistent over different outcomes including MADRS subscales and HAMA, and the difference in efficacy between UPD and BPD was non-significant. These findings are consistent with previous studies in young adults,^26,27 although the current response rate (85%) was slightly higher.^24,51 This may be because the patients in our trial suffered from more severe depression combined with a higher rate of psychotic symptoms, which may predict particularly good ECT responses compared with patients with mild-to-moderate depression.⁵²

Our repeated symptom assessment revealed that the largest clinical improvements occurred during the first 3–4 ECT sessions for most patients, with a plateau of response after approximately four ECT sessions. The MADRS trajectories were similar in the UPD and BPD subgroups. This finding is consistent with previous studies showing that ECT resulted in a rapid decline in depressed symptom ratings over the early course of treatment and that the symptom change was non-linear,^53,54 which might represent a common pattern of depression relief from ECT, regardless of depression type, treatment sensitivity, severity, and electrode placement. We previously proposed a simple but completely novel ECT protocol involving low-charge electrotherapy (Hybrid-ECT),⁵⁵ and our pilot trial showed that Hybrid-ECT may have similar antidepressant effects but with fewer side-effects.⁵⁶ We hope there will be more studies developing new ECT protocols that exploit the characteristics of the non-linear symptom relief curve.

Existing data suggest that the long-term outcomes of ECT are poor.^57,58 Over half of patients with depression relapsed by one year following successful initial treatment with ECT, with the majority relapsing within the first six months.⁵⁷ Our data show that nearly two-thirds of patients who respond to acute ECT relapsed after one month regardless of subtype, as previously reported.⁵⁹ Although most patients received continuation pharmacotherapy, relapse rates following ECT are disappointingly high. Young adults with TRD are vulnerable to relapsing depression related to life stresses including separation, individuation, and identity formation.¹² It has been reported that continuation or maintenance of ECT might prevent depression recurrence after initial response to ECT.^59,60

Subjective and Objective Cognitive Function

The cognitive side-effects of ECT, especially memory impairment, have received a lot of attention.^46,61–65 We evaluated subjective and objective cognitive function after every ECT and found an unexpected discrepancy between subjective and objective cognitive outcomes, similar to a recent study.⁶⁴

By exploiting repeated evaluation, we found that subjective cognitive complaints significantly increased during ECT and were still present at one-month follow-up. This result is consistent with a recent study showing that the number of ECT was associated with subjective cognition: more sessions received, higher prevalence of complaints.⁴⁵ Furthermore, subjective cognitive complaints did not decrease over time following treatment.⁴⁵ There are several possible reasons. First, we used bitemporal ECT, which is usually considered to be associated with more cognitive effects than unilateral ECT.⁴⁵ Second, younger patients with more depressive symptoms overreported cognitive impairments.^64,66,67 The patients in our study were young adults who have greater access to the media and internet and who may have learned about the side-effects of ECT to negatively affect their expectations. This expectation may also have induced a “nocebo effect”, a negative effect of a pharmacological or non-pharmacological treatment due to patient expectations.⁶⁸ Third, younger patients may be more concerned about cognitive deficits because they impede educational attainment and occupational and interpersonal functioning.⁶⁹ In addition, patients with TRD and a longer disease course may experience more failures related to cognitive abilities, which may maintain negative self-perceptions that exacerbate their perceived cognitive difficulties.⁷⁰

Conversely, for objective cognitive function, there were no significant changes after ECT treatment as measured with the total RBANS score and visuospatial/constructional, language, and attention subscales. Not only that, there was a significant and consistent increase in memory as measured by the FDST and RBANS subscales, including immediate and delayed memory. Consistent with our results, some studies have also detected improvements in several cognitive domains after ECT,^61–63 although many have similarly detected acute reduced cognition.^27,65,71 These conflicting results may be for several reasons. First, a brief stimulus may significantly reduce adverse cognitive effects,^62,72 especially with an ultra-brief pulse of no more than 0.5 ms.^61,62 Second, ECT increases hippocampal neurogenesis in adults.^73–75 Young adults may have more hippocampal neurogenesis after ECT than older individuals.⁷³ Neurogenesis-mediated inhibition reduces memory interference and enables reversal learning in both neutral and emotionally charged situations. This increased cognitive flexibility in turn may help reduce anxiety- and depression-like behaviors.⁷⁴

However, the improvement in objective memory was not linear. The FDST trajectory in the TRD group had a slight “S”-shape: increasing over the first 4 visits, decreasing from visits 5–7, and then increasing again. The decrease from visits 5–7 in TDR patients may be due to a cumulative effect of repeated ECT sessions. ECT-induced neurogenesis may lead to abnormal clearance of old memories or a failure to form new memories in the hippocampus, subsequently disrupting memory processes and storage.^76,77 We speculate that this may be the reason why there was a slight decline in memory in the later stages of ECT, even though objective memory after the entire course of ECT was significantly better than baseline.

Furthermore, in the follow-up phase, patients showed significantly improved objective cognition than during acute ECT in terms of total RBANS score and the immediate memory, attention, and delayed memory sub-scores. These results are in keeping with previous studies showing that working memory and some aspects of executive function improved beyond baseline after two weeks posttreatment.^65,78 In short, the impact and mechanisms of ECT on memory deserve further detailed exploration.

Limitations

There are limitations that mean care should be taken extrapolating our conclusions. The cognitive measurements after ECT were relatively simple, due to the difficulty in implementation and limited energy of patients. Another likely explanation for the subjective memory impairment results was that retrograde memory functioning was not assessed. This is the cognitive side effect of ECT and also limitation to the current study. Furthermore, we found a practice effect for FDST, which may counteract the cognitive impairment associated with ECT, considering the possibility of drop-out at follow-up and difficulties in trial implementation, we selected age-, sex-, and education-matched HCs to adjust for the practice effect. The absence of “no-ECT” depression group is another limitation; however, given that this was a group of drug-resistant patients with limited medication changes while receiving ECT, it is unlikely that changes in antidepressant medication had significant impacts on the main results. Furthermore, about 25% of patients were lost to follow-up at one month, mainly due to the COVID-19 pandemic. We had no detailed neurological status for these patients, which could have had a major impact on cognitive status.

Conclusion

ECT is an effective treatment for young adults with TRD. Although there was an increase in SMI with treatment, objective impairments in cognition were not observed. We also recommend using repeated evaluation in future studies to detect subtle changes related to ECT. Clinicians can inform patients about the characteristics of cognitive adverse effects of ECT. They may experience more subjective cognition problems than objective cognition. On this basis, they may need more subjective cognitive training.

Acknowledgments

We would like to thank Dezhen Su, Cai Nan, Li Wang, Cheng Chen, Maolin Hu, Gui Gui, Chang Shu, Hao Liu, Xin Guo, Baoli Zhang, Junhui Guo and other medical staff from the Department of Psychiatry in Renmin Hospital of Wuhan University, for their assistance of participants recruitment. We also acknowledge language editorial assistance from Nextgenediting.

Funding

This work was supported by grants from the National Natural Science Foundation of China (grant number: U21A20364) and the National Key R&D Program of China (grant number: 2018YFC1314600).

Disclosure

The authors declare that there is no conflict of interest in this work.

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