OBJECTIVES: To investigate comprehensive electroconvulsive therapy (ECT) in Japan. METHOD: From January 1 to December 31 in 2008, a 20-item questionnaire inquiring about ECT practice during the past year was sent to 1,463 institutions. RESULTS: 875 (59.8%) institutions completed the questionnaires. ECT was performed in 356 hospitals (40.7 %). Modified ECT (m-ECT) was performed in 135 hospitals (35.7%), unmodified ECT (u-ECT) in 160 (44.9%), and both m-ECT and u-ECT were performed in 47 (13.2%) hospitals. The range of receiving m-ECT varied according to the area in our country from 28.9% to 76.5% . A total of 42,358 ECTs were performed a year in our country. There were 29,040 (68.6%) m-ECTs and 13,186 (31.1%) u-ECTs. Although the percentage of m-ECTs was above 90% in the university hospitals and general hospitals, it was 48.8% in mental hospitals. In Japan, the percentage of m-ECT has increased, but some problems exist.

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The use of modified ECT is becoming more frequent in Japan, but a few problems still remain in order to further increase the application of modified ECT. Thus, we held an ECT networking meeting in Tokyo in February 2008. The aims of this conference were to promote sharing of information about ECT, cooperation with anesthesiologists and the safety of ECT. This networking will facilitate solving some of the problems with the use of ECT in Japan. It is the author's hope that this description of modified ECT will provide a sufficient amount information and support to allow the reader to make a more informed decision before having ECT.

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The Kinki ECT conference, in December of 2006, was established against the background of the unclearness of the ECT usage situation, and it was the basis to discuss various problems concerning ECT in the Kinki district. Based on a questionnaire survey of ECT usage, high interest, its effectiveness and safety, and the ethics concerning ECT were confirmed. However, an unfavorable impression of ECT was vaguely lingering. Therefore, it was recommended to improve the impression of ECT, and to provide educatation for the necessity of maintenance of ECT and outpatient ECT. Through the activity of the Kinki ECT conference, the institutions participating in the conference increased to 21 in three years. As for the shift to modified ECT, the making of the clinical pass, the ECT adaptation conference, the many examinations and evaluations before and after ECT, the shift to maintenance ECT, and so on, considerable progress was seen in each institution. Furthermore, the ECT network system was requested in which a patient could be introduced smoothly and promptly from the mental clinics, the single psychiatry department hospitals and the general hospitals to the ECT nucleus hospitals. In the network, a common form with detailed patient information will be used in the ECT introduction center.

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The author introduces the present state of electroconvulsive therapy in the Chugoku district and the community cooperation between 3 general hospital psychiatric units with psychiatric wards, which can provide modified electroconvulsive therapy, and other psychiatric hospitals and clinics in Hiroshima City. The number of patients treated with modified electroconvulsive therapy in the above 3 general hospitals in 2008 were 39 in total, and 36 for the net total. A total of 335 electroconvulsive therapy sessions were performed with 8.6 sessions on average for each patient. Twenty four patients (66.7% ) were diagnosed with major depressive disorder or bipolar disorder. Eleven patients (31% ) and other 6 patients (16.7% ) were referred from psychiatric clinics and psychiatric hospitals, respectively. Thirteen patients of the referred 21 patients subsequently received outpatient or inpatient treatment in the same psychiatric clinics and psychiatric hospitals as before for referral of electroconvulsive therapy. Community cooperation for electroconvulsive therapy, in which general hospital psychiatric units treat referred patients with modified electroconvulsive therapy and psychiatric clinics and psychiatric hospitals provide continuous treatment for them, are supposed to modestly function in Hiroshima City. To build the framework of community cooperation that makes it possible to provide modified electroconvulsive therapy quickly and adequately in psychiatric emergency hospitals, the Hiroshima Prefecture ECT Network has been established and conducts regular meetings and activities.

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I visited three typical ECT facilities in USA （Duke University, Mayo Clinic and Zucker Hillside Hospital）. I reported this experience and showed characteristics of ECT in USA.

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Self-reported questionnaires (containing questions inquiring about information services and psychological care/support provided by medical staff during disease notification, medical treatment, and disclosure of recurrence, etc.) were sent to cancer patients and cancer survivors through the Internet. The results showed that the subjects considered psychological care/support to be in a more informal setting. In addition, it was found that the quality and quantity of information at the time of disease notification and disclosure of recurrence, i.e. information service, differed widely, and that 89.7% of the care donors at the disease notification stage and 91.4% of them at the disclosure of recurrence stage were attending physicians. On the other hand, 55.8% of the subjects conferred with someone at the disease notification stage, and almost all the advisers were private individuals. Furthermore, 47.2% of the subjects conferred with someone during the medical treatment, and 75.4% of the advisors were family members. Although only 32.2% of the subjects received psychological care/support during medical treatment, there were more medical staff advisors (excluding physicians) at this stage than at the time of cancer disclosures.
The present study suggests that providing more active psychological care/support during the time of information service and building of a new framework for patient counseling are essential. Also, it is very important to provide and familiarize consultation services to the patients under treatments and to explore the psychological care/support by the non-physician healthcare providers.

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To optimize the effectiveness of electroconvulsive therapy (ECT) for the treatment of mood disorder or psychosis, it is essential to induce adequate seizures at stimulus intensity above "therapeutic threshold," which means 50% to 150% above seizure threshold in bilateral electrode placement. When only inadequate seizures including missed or abortive ones are induced at a maximum intensity, augmentation of seizure induction is necessary. The authors report three patients with depression and bipolar disorder who received a course of acute ECT with bifrontal electrode placement. After only inadequate seizures were produced at their sessions, switching anesthetic (to thiamylal from propofol), using flumazenil as preanesthetic medication and administering oral sustained-released theophylline (200mg) the night before ECT, respectively, successfully augmented seizures as adequate. No adverse effects were observed in all cases. There have been only a few reports on augmentation of seizure induction in Japan, while a number of studies have been conducted mainly in America. No reports on theophylline augmentation from Japan can be found. According to APA's ECT Task Force Report, these augmentation methods remain controversial in their effectiveness. However, our cases suggest that the augmentation may be effective and safe. Moreover, not a few psychiatrists in Japan still tend to believe "The longer the seizure duration, the more effective the ECT." We emphasize that the aim of augmentation is not to induce motor seizures or prolong seizure duration, but to induce adequate seizures, which should be judged mainly by electroencephalogram during ECT.

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