29/10/2010
1. Evidence for efficacy and treatment modality
Predictors of response to electroconvulsive therapy obtained using the three factor structure of the Montgomery and Asberg Depression Rating Scale for treatment resistant depressed patients (2010) Okazaki M, Tominaga K, Higuchi H et al. J of ECT;26:87-90
MADRS items were grouped according to ‘dysphoria’, ‘retardation’ and ‘vegitative symptoms’. A positive outcome following ECT in 24 depressed patients as defined as at least a 50% reduction in MADRS score, was associated with a high ‘dysphoria’ score pre-treatment (reported sadness, pessimistic thoughts, suicidal ideas)
Electroconvulsive therapy is equally effective in unipolar and bipolar depression. (2010) Bailine S, Fink M, Knapp R et al Acta Psycdhiatr Scand; 121:431-436.
This was large NIMH funded, multi-centre, double blind, randomised control trial of three electrode placements – bilateral at 1.5 x threshold, right unilateral at 6 x threshold and bifrontal at 1.5 x threshold . One hundred and seventy patients were diagnosed as unipolar and 50 as bipolar depression and almost all were described as medication failures. The remission and response rates were similar at over 60% and were not affected by electrode placement. In addition mania was not precipitated in either group.
Electrode placement in electroconvulsive therapy (ECT). A review of the literature. (2010) Kellner CH, Tobias KG & Wiegand J. J of ECT;26:175-180
This is an invited review in a special edition of the Journal of ECT dedicated to ‘state of the art’ treatment. The authors review the evidence base for three types of electrode placement and conclude that current literature supports the effectiveness of bilateral, right unilateral and bifrontal ECT. Bilateral ECT is reported to produce a faster response and there is insufficient evidence to support bifrontal as an alternative. The experience of cognitive side-effects is dependent on doses employed for each treatment modality as well as other patient characteristics. Individual patient variables and response should guide the clinician with respect to choice or change of electrode placement in order to achieve optimal results. As yet there is no way to predict which patients will respond well to unilateral ECT.
Augmentation strategies in electroconvulsive therapy. (2010) Loo C, Simpson B &MacPherson R. J of ECT;26:200-207.
There appears to be little evidence in the published literature to support the practice of hyperventilation, pre treatment with caffeine or use of specific anaesthetic agents in relation to the efficacy of ECT.
2 Safety and cost-benefit analysis
Frequency of electroconvulsive therapy sessions in a course. (2010) Gangadhar BN & Thirthalli J. J of ECT;26:181-185.
The conclusion of this invited review in this special journal of ECT is that optimum treatment frequency is twice per week. A more rapid response may be achieved with ECT at three times per week but at the expense of increasing cognitive side-effects. Once a week treatment may be preferred for ECT in the cognitively impaired patient.
A review of continuation electroconvulsive therapy. Application, safety and efficacy. (2010) Trevino K, McClintock SM & Husain MM. J of ECT;26:186-195.
This review article includes a description of the only large scale, randomised, controlled trial of continuation ECT to date as well as retrospective and other smaller studies. The authors feel that there is now sufficient evidence to support the efficacy of continuation ECT in the prevention of relapse. Reported side-effects were consistent with those of an acute course but more evidence on therapeutic guidelines and safety is required before regulatory organisations like NICE endorse this form of treatment.
The course of depressive symptoms in unipolar depressive disorder during electroconvulsive therapy: a latent class analysis. (2010) Cinar S, Oude Voshaar RC, Janzing JGE et al. J of Affective Disorders; 124:141-147.
Response to ECT in this sample of 156 consecutive patients was classified according to speed of improvement into five groups – fast (39), intermediate (47), slow (30), slow with delayed onset (18) and no improvement (20). Identification of endpoint of the course of treatment can be difficult unless full remission is achieved.
3. Side effects of ECT
Objective cognitive performance associated with electroconvulsive therapy for depression: a systematic review and meta-analysis. (2010) Semkovska M & McLoughlin DM. Biol Psychiatry. Jbiopsych.2010.06.009.
This review of published literature to2009 included all studies in which cognition had been assessed. Twenty four cognitive variables were meta-analysed and significant deficits were noted to occur within three days of treatment, especially episodic memory and executive function. However from day three post ECT most deficits resolved and by day 15 there appeared to be an improvement in processing speed, working memory, anterograde memory and some aspects of executive function compared to pre-treatment baseline.
Pre- and post electroconvulsive therapy multidomain cognitive assessment in psychotic depression (2010) Bayless J, McCormick LM, Brumm MC et al. J of ECT;26:47-52.
The repeatable battery for the assessment of neuropsychological status (RBANS) was used to assess the cognitive function of 20 patients before and after ECT for the treatment of psychotic depression. Scores were compared with the Hamilton Rating Depression – 28 Scale(HRSD) and the Scale for Assessing Negative and Positive Symptoms (SANPS). Cognitive performance did not worsen after ECT and actually improved on some measures, relating to an improvement in negative symptoms.
The course of myalgia and headache after electroconvulsive therapy (2010) Dinwiddie SH, Huo D, Gottlieb O. J of ECT;26:116-120.
Headache and myalgia are common side-effects at ECT that, if severe, could possibly be reduced by preventative treatments. This survey of 29 patients found that headache was associated with a pre-ECT history of headaches, younger patients and longer seizure duration with a peak in intensity of pain at two hours post treatment. Myalgia was most severe after the first treatment and may be reduced by use of non depolarising muscle relaxants.
4. Mortality and suicide rates
5. Guidelines, audits and rating scales
A survey of the practice of electroconvulsive therapy in Asia (2010) Chanpattana W, Kramer BA, Kunigiri et al. J of ECT;26:5-10.
The authors of this 2 year survey of use of ECT in Asia suggest that outdated practice reflects a need for education and development rather than a misuse of ECT. Schizophrenia is the most common indication, unmodified ECT is still common, most using sine-wave electricity, EEG monitoring is unusual and no formal training is available.
This volume of the Journal of ECT is a special issue about ECT in Asia and lso contains more detailed information on ECT in Thailand and Hindi Cinema.
6. Attitudes and opinions
Predictors of patient satisfaction after ultrabrief bifrontal and unilateral electroconvulsive therapies for major depression.
(2010) Sienaert PA, Vansteelandt K, Demyttenaere K et al
Forty-eight patients completed a questionnaire at least 6 months following ultrabrief pulse bifrontal or unilateral ECT. Three out of the total of 48 questions related to satisfaction ie “glad” to have had treatment, would have ECT “again” and “satisfied” with the results. Seventy-three percent of patients were “glad” to have had treatment, 58% would have ECT “again” and the same number were “satisfied” with the result. The most satisfied were those who were not psychotic at baseline and whose mood and cognitive function improved most.
7. Anaesthesia for ECT
Rapid antidepressant effect of ketamine anaesthesia during electroconvulsive therapy of treatment resistant depression. (2010) Okamoto NA, Nakai T, Sakamoto K et al. J of ECT;26:223-227.
Ketamine is an NMDA receptor blocker and is used as an anaesthetic in view of its ability to suppress the cerebral cortex resulting in slow wave generation. It also stimulates the central limbic system which can result in euphoria and perceptual abnormalities and so potential for abuse. In addition it may lower seizure threshold and may also have some cognitive sparing abilities in view of suppression of excitotoxicity hence the interest in this agent for ECT anaesthesia. This was a small open label study of 31 patients assigned to either ketamine or propofol. The ketamine group showed a more rapid improvement as measured by a reduction in Hamilton Depression Rating Scores but there was no difference between groups by the end of the course of ECT. Adverse events are listed.
Electroconvulsive therapy-induced persistent retrograde amnesia: could it be minimised by ketamine or other pharmacological approaches? (2010) Gregory-Roberts EM, Naismith SL, Cullen KM et al. J of Affective Disorders;126:39-45.
This is a review of human studies between 1950 and 2009 in which cognitive function was assessed. Retrograde amnesia may result from disruption of long term potentiation. An NMDA blocker may prevent this disruption. Ketamine is an NMDA blocker and whilst there are some concerns with respect to its use with ECT in view of its psychomimetic effects the authors conclude that a clinical trial would be worthwhile to assess speed of action and possible reduction in cognitive side-effects compared to other agents.
8. Side-effects of antidepressants
9. Mechanisms of ECT action
Electroconvulsive therapy. A theory for the mechanism of action.
(2010) Frais AT. J of ECT;26:60-61
The author postulates that recovery from depression following ECT treatment relates to improvement in autobiographical memory and hence improved connection with personal identity.
Effect of electroconvulsive therapy on brain 5HT2 receptors in major depression. (2010) Yatham LN, Liddle PF, Lam RW et al. Brit J Psych;196:474-479.
This positron emission tomography (PET) study of 15 patients receiving ECT for treatment resistant depression found that, contrary to rat studies, there was down regulation of 5HT2 in limbic and pre-frontal areas of humans who responded. This finding is therefore in line with that of antidepressant response and the opposite of a previously held view that ECT exerted a different action from that of drug treatments.
Increase in hippocampal volume after electroconvulsive therapy in patients with depression. A volumetric magnetic resonance imaging study.
(2010) Nordanskog P, Dahlstrand U, Larsson MR et al. J of ECT;26:62-67
Hippocampal volumes, both left and right, increased after successful combined antidepressant and ECT in this prospective study of twelve depressed patients lending support to the theory that hippocampal volume loss is associated with depressive disorders. Mechanisms leading to the volume changes noted are postulated but there was no evidence of oedema
The level of serum brain derived neurotrophic factor is associated with the therapeutic efficacy of modified electroconvulsive therapy in Chinese patients with depression. (2010) Hu Y, Yu x, Yang F et al. J of ECT;26:121-125
There was a significant correlation in the rise of serum BDNF with improvement as measured by a fall in Hamilton rating score for depression in this prospective study of 28 patients. Patients with depression had lower serum BDNF with respect to controls at the outset, this rose to near normal levels at two weeks post successful treatment.
Electroconvulsive therapy stimulus parameters. Rethinking dosage. (2010) Peterchev AV, Rosa MA, Prudic J et al. J of ECT;26:159-174
This article, printed in a special edition of the Journal of ECT focussing on effectiveness of treatment, describes the components that make up total charge or energy. It may be that attention to machine variables such as pulse width, pulse shape, pulse amplitude, frequency and length of pulse train prove important in optomising treatment but as yet there is no definitive evidence. A biomedical overview of ECT is included.
9. Other Physical Therapies
Neurophysiological characterization of high-dose magnetic seizure therapy. (2009) Cycowicz Y, Luber B, Spellman T et al. J of ECT;25:157-164.
This is a small, case control study that looked to identify differences between EEG characteristics and cognitive effects following either electroconvulsive seizures (ECS) or high dose magnetic seizures (MST) induced in rhesus monkeys. The results add to the evidence base for differential patterns of ictal expression and rate of cognitive side-effects.