{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T19:42:37Z","timestamp":1791315757184,"version":"4.3.1"},"reference-count":37,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T00:00:00Z","timestamp":1784073600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T00:00:00Z","timestamp":1784073600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/501100001826","name":"ZonMw","doi-asserted-by":"publisher","award":["848015012"],"award-info":[{"award-number":["848015012"]}],"id":[{"id":"10.13039\/501100001826","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Acta Psychiatr Scand"],"abstract":"ABSTRACT<\/jats:title>\n \n Introduction<\/jats:title>\n \n Postictal agitation (PIA) is an impactful confusional state occasionally occurring after electroconvulsive therapy (ECT). PIA creates dangerous situations for caregivers and patients, prolongs lead times, and sometimes leads to the premature discontinuation of ECT. Despite the impact PIA can have on patients and caregivers, little is known about its incidence and the factors associated with its occurrence. This study aims to investigate putative prognostic factors for PIA.<\/jats:styled-content>\n <\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n We utilized data from the \u201cRivastigmine for ECT\u2010induced Cognitive Adverse effects in Late\u2010Life depression\u201d (RECALL) prospective cohort study; a study on older adults (<\/jats:styled-content>\n \u2265\u2009\n 55\u2009years) with a major depressive episode receiving ECT. We investigated several putative prognostic factors based on previous research, biological plausibility, and availability. PIA was defined by either a Richmond Agitation\u2010Sedation score<\/jats:styled-content>\n \u2265\u2009\n 2 or the administration of emergency medication specifically for PIA. Mixed\u2010effects logistic regression was used to analyze univariate and adjusted odds ratios for the prognostic factors.<\/jats:styled-content>\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n We included 142 patients who received 1838 ECT sessions. The incidence of PIA was 34.5% at the patient\u2010level and 9.2% at the session\u2010level. A small subset of older adults (19.7%) accounted for 87.5% of all PIA occurrences. We found that male sex, flumazenil use, and a longer seizure duration were associated with higher odds of developing PIA. Multi\u2010seizure sessions and a higher level of education were associated with lower occurrence of PIA.<\/jats:styled-content>\n <\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n \n This study identified sex, flumazenil use, seizure duration, the amount of seizures during a session, and education level as prognostic factors for PIA. The pronounced clustering of PIA events within a small subset of patients suggests meaningful interindividual vulnerability, but should be replicated in future studies. If confirmed, these findings could provide actionable insights for preventive treatment strategies. In particular, the use of flumazenil should be critically reconsidered in persons experiencing PIA.<\/jats:styled-content>\n <\/jats:p>\n \n \n Trial Registration:<\/jats:bold>\n EudraCT 2014\u2010003385\u201024.\n <\/jats:styled-content>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1111\/acps.70128","type":"journal-article","created":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T06:03:27Z","timestamp":1784181807000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Prognostic Factors for Postictal Agitation After Electroconvulsive Therapy in Older Adults With Depression"],"prefix":"10.1111","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5974-4424","authenticated-orcid":false,"given":"Thomas C.","family":"Feenstra","sequence":"first","affiliation":[{"name":"GGZ Centraal Mental Health Care Amersfoort the Netherlands"},{"name":"Amsterdam Public Health Research Institute Mental Health Program Amsterdam the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-9943-6905","authenticated-orcid":false,"given":"Natascha","family":"den Bleijker","sequence":"additional","affiliation":[{"name":"GGZ Centraal Mental Health Care Amersfoort the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4784-0712","authenticated-orcid":false,"given":"Adriaan W.","family":"Hoogendoorn","sequence":"additional","affiliation":[{"name":"Department of Psychiatry Amsterdam UMC Location Vrije Universiteit Amsterdam Amsterdam the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huda","family":"Gafer","sequence":"additional","affiliation":[{"name":"GGZ inGeest Mental Health Care Amsterdam the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5886-1597","authenticated-orcid":false,"given":"Nathalie","family":"Denayer","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, University Psychiatric Center KU Leuven Academic Center for ECT and Neuromodulation (AcCENT), KU Leuven Leuven Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric","family":"van Exel","sequence":"additional","affiliation":[{"name":"Amsterdam Public Health Research Institute Mental Health Program Amsterdam the Netherlands"},{"name":"Department of Psychiatry Amsterdam UMC Location Vrije Universiteit Amsterdam Amsterdam the Netherlands"},{"name":"GGZ inGeest Mental Health Care Amsterdam the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9856-6920","authenticated-orcid":false,"given":"Rob M.","family":"Kok","sequence":"additional","affiliation":[{"name":"Parnassia Psychiatric Institute The Hague the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karina","family":"Somers","sequence":"additional","affiliation":[{"name":"Parnassia Psychiatric Institute The Hague the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7944-1487","authenticated-orcid":false,"given":"Anton C. M.","family":"Vergouwen","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Medical Psychology OLVG Hospital Amsterdam the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adriano","family":"van der Loo","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Medical Psychology OLVG Hospital Amsterdam the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-1099-0333","authenticated-orcid":false,"given":"Esm\u00e9e","family":"Verwijk","sequence":"additional","affiliation":[{"name":"Department of Medical Psychology Amsterdam UMC Amsterdam the Netherlands"},{"name":"Department of Psychology, Brain and Cognition University of Amsterdam Amsterdam the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Filip","family":"Bouckaert","sequence":"additional","affiliation":[{"name":"University Psychiatric Center KU Leuven, Department of Geriatric Psychiatry Leuven Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aartjan T. F.","family":"Beekman","sequence":"additional","affiliation":[{"name":"Department of Psychiatry Amsterdam UMC Location Vrije Universiteit Amsterdam Amsterdam the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0650-415X","authenticated-orcid":false,"given":"Pascal","family":"Sienaert","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, University Psychiatric Center KU Leuven Academic Center for ECT and Neuromodulation (AcCENT), KU Leuven Leuven Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Didi","family":"Rhebergen","sequence":"additional","affiliation":[{"name":"GGZ Centraal Mental Health Care Amersfoort the Netherlands"},{"name":"Department of Psychiatry Amsterdam UMC Location Vrije Universiteit Amsterdam Amsterdam the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,7,15]]},"reference":[{"issue":"386","key":"e_1_2_13_2_1","doi-asserted-by":"crossref","first-page":"667","DOI":"10.1056\/NEJMra2034954","article-title":"Electroconvulsive Therapy","volume":"17","author":"Espinoza R. T.","year":"2022","journal-title":"New England Journal of Medicine"},{"key":"e_1_2_13_3_1","doi-asserted-by":"crossref","first-page":"274","DOI":"10.1016\/j.jagp.2014.05.002","article-title":"Older Age Is Associated With Rapid Remission of Depression After Electroconvulsive Therapy: A Latent Class Growth Analysis","volume":"23","author":"Rhebergen D.","year":"2015","journal-title":"American Journal of Geriatric Psychiatry"},{"key":"e_1_2_13_4_1","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1192\/bjp.2024.126","article-title":"Electroconvulsive Therapy Response and Remission in Moderate to Severe Depressive Illness: A Decade of National Scottish Data","volume":"225","author":"Semple D. M.","year":"2024","journal-title":"British Journal of Psychiatry"},{"key":"e_1_2_13_5_1","doi-asserted-by":"crossref","first-page":"1915","DOI":"10.1038\/s41380-024-02803-2","article-title":"A Prediction Model for Electroconvulsive Therapy Effectiveness in Patients With Major Depressive Disorder From the Dutch ECT Consortium (DEC)","volume":"30","author":"Loef D.","year":"2025","journal-title":"Molecular Psychiatry"},{"key":"e_1_2_13_6_1","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1192\/bjp.2017.28","article-title":"Prediction of Electroconvulsive Therapy Response and Remission in Major Depression: Meta\u2010Analysis","volume":"212","author":"Van Diermen L.","year":"2018","journal-title":"British Journal of Psychiatry"},{"issue":"74","key":"e_1_2_13_7_1","doi-asserted-by":"crossref","first-page":"779","DOI":"10.1001\/jamapsychiatry.2017.1670","article-title":"Modern Electroconvulsive Therapy: Vastly Improved Yet Greatly Underused","volume":"1","author":"Sackeim H. A.","year":"2017","journal-title":"JAMA Psychiatry"},{"key":"e_1_2_13_8_1","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1192\/bjp.2025.2","article-title":"Autobiographical Memory After Electroconvulsive Therapy: Systematic Review and Meta\u2010Analysis","volume":"228","author":"Mathiassen A. B.","year":"2026","journal-title":"British Journal of Psychiatry"},{"issue":"68","key":"e_1_2_13_9_1","doi-asserted-by":"crossref","first-page":"568","DOI":"10.1016\/j.biopsych.2010.06.009","article-title":"Objective Cognitive Performance Associated With Electroconvulsive Therapy for Depression: A Systematic Review and Meta\u2010Analysis","volume":"15","author":"Semkovska M.","year":"2010","journal-title":"Biological Psychiatry"},{"key":"e_1_2_13_10_1","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1111\/acps.13803","article-title":"Confusional States During Electroconvulsive Therapy for Late\u2010Life Depression: A Prospective Cohort Study","volume":"152","author":"Feenstra T. C.","year":"2025","journal-title":"Acta Psychiatrica Scandinavica"},{"issue":"39","key":"e_1_2_13_11_1","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1097\/YCT.0000000000000891","article-title":"Postanesthesia Recovery Unit Optimization for Patients With Postictal Agitation Secondary to Electroconvulsive Therapy","volume":"1","author":"Arora V.","year":"2023","journal-title":"Journal of ECT"},{"key":"e_1_2_13_12_1","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1097\/YCT.0000000000001032","article-title":"Prognostic Factors and Incidence for Postictal Agitation After Electroconvulsive Therapy: A Systematic Review and Meta\u2010Analysis","volume":"41","author":"Ertman M.","year":"2025","journal-title":"Journal of ECT"},{"key":"e_1_2_13_13_1","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1097\/YCT.0000000000000866","article-title":"Severe Postictal Confusion After Electroconvulsive Therapy: A Retrospective Study","volume":"39","author":"Schuur G.","year":"2023","journal-title":"Journal of ECT"},{"key":"e_1_2_13_14_1","doi-asserted-by":"crossref","first-page":"180","DOI":"10.1111\/j.1440-1819.2009.01930.x","article-title":"Identification of Predictors of Post\u2010Ictal Delirium After Electroconvulsive Therapy","volume":"63","author":"Kikuchi A.","year":"2009","journal-title":"Psychiatry and Clinical Neurosciences"},{"key":"e_1_2_13_15_1","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1097\/00124509-200009000-00007","article-title":"Post\u2010ECT Agitation and Plasma Lactate Concentrations","volume":"16","author":"Auriacombe M.","year":"2000","journal-title":"Journal of ECT"},{"issue":"39","key":"e_1_2_13_16_1","doi-asserted-by":"crossref","first-page":"136","DOI":"10.1097\/YCT.0000000000000886","article-title":"Acute and Prophylactic Management of Postictal Agitation in Electroconvulsive Therapy","volume":"1","author":"Sterina E.","year":"2023","journal-title":"Journal of ECT"},{"key":"e_1_2_13_17_1","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1097\/YCT.0b013e3182887b5b","article-title":"Postictal Agitation After Electroconvulsive Therapy: Incidence, Severity, and Propofol as a Treatment Option","volume":"29","author":"Tzabazis A.","year":"2013","journal-title":"Journal of ECT"},{"key":"e_1_2_13_18_1","doi-asserted-by":"crossref","first-page":"150","DOI":"10.1097\/YCT.0000000000000393","article-title":"Benefits of Dexmedetomidine in Management of Post\u2010ECT Agitation","volume":"33","author":"Narang P.","year":"2017","journal-title":"Journal of ECT"},{"key":"e_1_2_13_19_1","doi-asserted-by":"crossref","DOI":"10.3389\/fpsyt.2022.953686","article-title":"Rivastigmine for ECT\u2010Induced Cognitive Adverse Effects in Late Life Depression (Recall Study): A Multicenter, Randomized, Double Blind, Placebo\u2010Controlled, Cross\u2010Over Trial in Patients With Depression Aged 55\u2009Years or Older: Rationale, Objectives and Methods","volume":"13","author":"Henstra M. J.","year":"2022","journal-title":"Frontiers in Psychiatry"},{"issue":"166","key":"e_1_2_13_20_1","doi-asserted-by":"crossref","first-page":"1338","DOI":"10.1164\/rccm.2107138","article-title":"The Richmond Agitation\u2010Sedation Scale: Validity and Reliability in Adult Intensive Care Unit Patients","volume":"15","author":"Sessler C. N.","year":"2002","journal-title":"American Journal of Respiratory and Critical Care Medicine"},{"key":"e_1_2_13_21_1","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1097\/EJA.0000000000001113","article-title":"Preventive Effect of Dexmedetomidine on Postictal Delirium After Electroconvulsive Therapy: A Randomised Controlled Study","volume":"37","author":"Qiu Z.","year":"2020","journal-title":"European Journal of Anaesthesiology"},{"key":"e_1_2_13_22_1","volume-title":"International Standard Classification of Education: ISCED 2011","author":"Unesco Institute For Statistics","year":"2012"},{"key":"e_1_2_13_23_1","first-page":"2101","article-title":"Morbidity Figures From General Practice, Data From Four General Practices 1978\u20101982","volume":"130","author":"Van Den Hoogen H. J. M.","year":"1986","journal-title":"Nederlands Tijdschrift voor Geneeskunde"},{"key":"e_1_2_13_24_1","doi-asserted-by":"crossref","first-page":"382","DOI":"10.1192\/bjp.134.4.382","article-title":"A New Depression Scale Designed To Be Sensitive to Change","volume":"134","author":"Montgomery S. A.","year":"1979","journal-title":"British Journal of Psychiatry"},{"key":"e_1_2_13_25_1","doi-asserted-by":"crossref","first-page":"893","DOI":"10.1037\/0022-006X.56.6.893","article-title":"An Inventory for Measuring Clinical Anxiety: Psychometric Properties","volume":"56","author":"Beck A. T.","year":"1988","journal-title":"Journal of Consulting and Clinical Psychology"},{"key":"e_1_2_13_26_1","first-page":"189","article-title":"Mini\u2010Mental State. A Practical Method for Grading the Cognitive State of Patients for the Clinician","volume":"12","author":"Folstein M. F.","year":"1975","journal-title":"Journal of Psychiatric Research"},{"key":"e_1_2_13_27_1","doi-asserted-by":"crossref","first-page":"192","DOI":"10.1093\/bjaceaccp\/mkq039","article-title":"Anaesthesia for Electroconvulsive Therapy","volume":"10","author":"Uppal V.","year":"2010","journal-title":"Continuing Education in Anaesthesia Critical Care & Pain"},{"issue":"8","key":"e_1_2_13_28_1","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2024.62054","article-title":"Tolerability and Clinical Outcomes With Anesthesia Dose Reduction During Electroconvulsive Therapy","volume":"3","author":"Espinola C. W.","year":"2025","journal-title":"JAMA Network Open"},{"key":"e_1_2_13_29_1","first-page":"93","article-title":"Electroconvulsive Therapy. Indications, Procedure and Treatment Results","volume":"82","author":"Folkerts H. W.","year":"2011","journal-title":"Der Nervenarzt"},{"key":"e_1_2_13_30_1","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001380","article-title":"Prognosis Research Strategy (Progress) 2: Prognostic Factor Research","volume":"10","author":"Riley R. D.","year":"2013","journal-title":"PLoS Medicine"},{"key":"e_1_2_13_31_1","first-page":"978","article-title":"The Flumazenil in Benzodiazepine Intoxication Multicenter Study Group","volume":"14","author":"Treatment of Benzodiazepine Overdose with Flumazenil","year":"1992","journal-title":"Clinical Therapeutics"},{"key":"e_1_2_13_32_1","doi-asserted-by":"crossref","first-page":"e49","DOI":"10.1097\/YCT.0000000000001003","article-title":"Effectiveness and Safety of Flumazenil Augmentation During Electroconvulsive Therapy","volume":"40","author":"Gistelinck L.","year":"2024","journal-title":"Journal of ECT"},{"key":"e_1_2_13_33_1","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1097\/YCT.0000000000000137","article-title":"Multifactorial Determinants of the Neurocognitive Effects of Electroconvulsive Therapy","volume":"30","author":"Mcclintock S. M.","year":"2014","journal-title":"Journal of ECT"},{"key":"e_1_2_13_34_1","doi-asserted-by":"crossref","DOI":"10.1016\/j.brs.2026.103031","article-title":"Postictal Agitation Is Associated With Brain\u2010Wide Postictal Microstructural Changes After Electroconvulsive Therapy\u2010Induced Seizures","volume":"19","author":"Verdijk J.","year":"2026","journal-title":"Brain Stimulation"},{"key":"e_1_2_13_35_1","doi-asserted-by":"crossref","first-page":"1045","DOI":"10.1111\/epi.16519","article-title":"The Postictal State \u2010 What Do We Know?","volume":"61","author":"Pottkamper J. C. M.","year":"2020","journal-title":"Epilepsia"},{"issue":"349","key":"e_1_2_13_36_1","doi-asserted-by":"crossref","first-page":"321","DOI":"10.1016\/j.jad.2024.01.049","article-title":"Pre\u2010Treatment Predictors of Cognitive Side\u2010Effects After Treatment With Electroconvulsive Therapy in Patients With Depression: A Multicenter Study","volume":"15","author":"Loef D.","year":"2024","journal-title":"Journal of Affective Disorders"},{"key":"e_1_2_13_37_1","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1097\/YCT.0000000000000383","article-title":"ECT\u2010Related Anxiety: A Systematic Review","volume":"33","author":"Obbels J.","year":"2017","journal-title":"Journal of ECT"},{"issue":"2","key":"e_1_2_13_38_1","doi-asserted-by":"crossref","first-page":"116","DOI":"10.1111\/acps.70095","article-title":"Lithium, Electroconvulsive Therapy and Cognition: A Systematic Review and Meta\u2010Analysis","volume":"154","author":"Van Den Eynde L.","year":"2026","journal-title":"Acta Psychiatrica Scandinavica"}],"container-title":["Acta Psychiatrica Scandinavica"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/acps.70128","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/acps.70128","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/acps.70128","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T06:03:31Z","timestamp":1784181811000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/acps.70128"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,15]]},"references-count":37,"alternative-id":["10.1111\/acps.70128"],"URL":"https:\/\/doi.org\/10.1111\/acps.70128","archive":["Portico"],"relation":{},"ISSN":["0001-690X","1600-0447"],"issn-type":[{"value":"0001-690X","type":"print"},{"value":"1600-0447","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,15]]},"assertion":[{"value":"2026-03-27","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-07-06","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-07-15","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"acps.70128"}}