Appendix 1

True/False Questions

Choose the best answer for each statement.

Question / True / False
The most common indication for ECT is treatment-resistant depression.
ECT is an effective treatment for psychotic symptoms.
ECT is first-line treatment for schizophrenia.
ECT causes permanent brain damage.
Systolic blood pressure of greater than 160mmHg is an absolute contraindication for ECT.
Ischemic cardiac disease is an absolute contraindication for ECT.
Reactive airway disease is an absolute contraindication to ECT.
An increased Intracranial mass lesion is an absolute contraindication for ECT.
ECT is not as effective as antidepressant medication in the treatment of major depressive disorder.
ECT causes personality changes.
ECT is associated with acute mild impairment in the ability to retain newly learned information (anterograde amnesia).
ECT is associated with acute impairment in the ability to recall events that occurred in the weeks prior to treatment (retrograde amnesia).
ECT performed with unilateral lead placement is associated with greater severity of cognitive impairment than ECT performed with bilateral lead placement.
The Folstein Mini Mental State Exam (MMSE) screens for cognitive deficits following ECT.
ECT involves the delivery of an electrical stimulation to induce a convulsion.
ECT performed under general anesthesia.
ECT causes a decrease in seizure threshold
The Physical Health Questionnaire-9 (PHQ-9) is a screen for major depression, but does not measure severity of depression.
The Physical Health Questionnaire-9 (PHQ-9) measures severity of depression.
There are legal provisions for the involuntary administration of ECT.
All anesthetic induction agents affect duration of both the EMG and EEG seizure.

Multiple Choice Questions

*1. A 65-year-old woman with treatment-resistant depression is being referred for ECT.
Which ONE of the following conditions is the strongest contraindication to ECT?
A. Atrial fibrillation with pacemaker
B. Baseline systolic blood pressure of greater than 160mmHg
C. Intracranial mass lesion with increased intracranial pressure
D. Parkinson’s disease with severe bilateral tremor
E. Reactive airway disease requiring steroid treatment
*2. An 85-year-old man with treatment-resistant depression and early senile dementia of the Alzheimer’s type is being referred for ECT.
Which ONE of the following tests is the best for determining severity of depression?
A. Minnesota Multiphasic Personality Inventory (MMPI)
B. Mini-Mental State Examination (MMSE)
C. Myers-Briggs Personality Test
D. Physical Health Questionnaire-9 for Depression (PHQ-9)
E. Semantic Fluency Test (Animal Naming)
*3. A 63-year-old man with a history of recurrent depression was admitted to the psychiatric inpatient unit.
Which ONE of the following patient characteristics most strongly predicts LACK of response to ECT?
A. He had been working full-time as an accountant, with two children, and full social life prior to onset of depression.
B. He had been depressed for 8-9 months prior to admission.
C. He had not responded to four 6-8 week trials of different antidepressants
D. At the time of admission, he was severely guilt-ridden that he had caused global warming.
E. He attempted suicide by overdose of trazodone (Desyrel) just prior to admission.
*4. A 38-year-old woman with treatment-resistant depression is contemplating ECT treatment. She would like more information about potential side effects of ECT.
What are the five most common side effects that patients undergoing ECT experience?
A. Anemia
B. Aspiration pneumonia
C. Brain damage
D. Epilepsy
E. Headaches
F. Hearing loss
G. Meningioma
H. Muscle aches
I. Nausea
J. Personality changes
K. Reactive airway disease
L. Retrogradeamnesia
M. Transient confusion
N. Transient rash
O. Transient tinnitus
P. Visual hallucinations
*5. A 92-year-old woman with recurrent depression, cardiovascular disease, and mild Alzheimer’s dementia is being referred for ECT. You are asked to assess her capacity
to consent to ECT. She says, “So I’ve heard that ECT causes brain damage, but I’m willing to take that risk. But I am not sure, maybe I really don’t want ECT because there
is a risk of headache. Then you tell me some people have had problems with memory after the ECT. And that my blood pressure might get even higher during ECT, but I
guess I do trust you and the other doctors to take care of it. I guess I want to have ECT because I have been so depressed.”
Which one of the following statements made by the patient MOST supports the assessment that the patient is NOT capable of making an informed decision?
A. “ …maybe I really don’t want ECT because there is a risk of headache.”
B. “…ECT causes brain damage…I’m willing to take that risk.” *
C. “…my blood pressure may get even higher during ECT, but I trust you and the other doctors to take care of it.”
D. “…some people have had problems with memory after the ECT.”
E. “I want to have ECT because I have been so depressed.”
*6. A 55-year-old woman with severe recurrent depression did not respond to individual supportive psychotherapy, nor trials of fluoxetine, mirtazapine, or aripiprazole.
Following these modalities, her depression remitted after treatment with 9 ECT sessions.
There is strongest evidence of maintenance of remission of depression for which ONE of the following maintenance interventions?
A. Cognitive-behavioral psychotherapy twice weekly
B. Exercise and nutritional counseling
C. Lithium and nortriptyline combination therapy
D. Nortriptylinemonotherapy
E. Psychodynamic psychotherapy twice weekly
*7a. A 76-year-old man with severe depression on the inpatient psychiatric ward is evaluated for electro-convulsive therapy. He appears poorly groomed and disheveled. He
speaks slowly and quite softly.
Which ONE of the following patient statements is MOST diagnostic of an underlying delirium?
A. “Yesterday, I forgot where I put my keys.”
B. “I don’t want to answer any of your damn-fool questions.”
C. “I have no idea what or where I am or what time it is.”
D. “I hear voices telling me to kill myself.”
E. “Electro-shock treatment! I’m not that depressed!”
*7b. A 76-year-old man with severe depression on the inpatient psychiatric ward is evaluated for electro-convulsive therapy. He appears poorly groomed and disheveled. He
speaks slowly and quite softly.
Which ONE of the following findings is MOST specific for the diagnosis of dementia?
A. Folate level of 18.5 (normal range: 2.7 - 17.0 ng/mL)
B. Impaired recall on Animal Naming Test
C. Increased latency of speech
D. Score of 28 or above on the Folstein Mini-Mental State Examination (MMSE)
E. TSH of 7.8 (normal range: 0.5-5.5 units)
*8. A 55-year-old woman with treatment-resistant major depression is undergoing ECT. Her initial pulse prior to the electrical stimulus is 85 bpm. Following the stimulus
and seizure onset her pulse immediately decreases to 58 bpm.
Which ONE of the following events would NOT be associated with an initial parasympathetic discharge?
A. asystole
B. hypotension
C. premature atrial contractions (PACs)
D. salivation
E. ventricular tachycardia
*9. A 48-year-old man, who being treated with phenelzine 10mg daily for major depression, is scheduled for ECT.
Which TWO of the following drugs are the safe to use in patients receiving MAOIs?
A. ephedrine
B. fentanyl
C. meperidine
D. metoprolol
*10. A 54-year-old female with severe depression and chronic renal failure is scheduled for ECT. Three months ago, she had a cerebrovascular accident that resulted in a
right lower extremity paresis. Initial electrolyte studies reveal a potassium level of 5.4 meq/L. (normal range: 3.5 - 5.5 mEq/L)
Following induction of anesthesia, which ONE of the following muscle relaxants should be avoided in this patient?
A. cis-atracurium
B. mivacurium
C. rocuronium
D. succinylcholine
E. vecuronium
*11. A 84-year-old man with treatment resistant depression is undergoing a course of ECT treatment. His current medications are bupropion 150mg twice daily and
lorazepam 1mg at bedtime. After the third treatment, the EMG seizure duration is 11 seconds and the EEG seizure duration is 18 seconds.
Which ONE of the following common maneuvers is MOST likely to decrease seizure duration?
A. Caffeine 250 mg I.V. five minutes prior to ECT stimulus.
B. Discontinuation of lorazepam on the evening before ECT treatment.
C. Doubling the energy of the ECT stimulus.
D. Hypoventilation of anesthetized patient before ECT stimulus
E. Switching anesthetic induction agent from methohexital to etomidate.

Post-Exercise Assessment of ECT Knowledge and Attitudes

A lot less comfortable / A little less comfortable / No change / A little more comfortable / A lot more comfortable
How did ECTAE affect your attitudestowards ECT?
(Compare to your attitudes before ECTAE)
I now rate my comfort level with…
Referring a patient with refractory depression for ECT as:
Referring a close relative with refractory depression for ECT as:
Undergoing ECT myself, if I suffered from treatment-refractory major depression, as:
How did ECTAE affect your competencyin performing these skills?
(Compare to your competency in these skills before ECTAE)
I now rate my competency for…
Mask ventilating a patient as:
Treating acute hypertension during and immediately following ECT as:

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