26/06/2012
9. Mechanisms of ECT action
Electroconvulsive therapy reduces frontal cortical connectivity in severe depressive disorder (2012) Perrin JS, Merz S, Bennett DM et al. PNAS doi/10.1073/pnas.1117206109.
This group from Aberdeen used functional neuro-imaging (MRI) to examine the effects of ECT on nine patients. There was a strong correlation between clinical improvement and reduced connectivity in the left dorsolateral prefrontal cortical region (Brodmann areas 44, 45 and 46). The findings add weight to the emerging “hyperconnectivity hypotheseis” in depression and showed that ECT has a lasting effect on the functional architecture of the brain.
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.