Scottish ECT Audit Network.

Evidence for efficacy & treatment modality

Socioeconomic status of patients receiving electroconvulsive therapy. (2013) Bennett DM, Cameron IM, Currie J et al. J of ECT;29:303-307.

The group set out to find out if the rate of ECT prescription increases with deprivation and if there is any effect of deprivation on outcome. There was no difference between the study and control groups in relation to either question therefore ECT for the more deprived was just as effective as for more affluent populations.

Usefulness of treatment reports for electroconvulsive therapy. (2013) Bennett DM, Fernie G, Currie J et al. J of ECT;29:201-213.

Selection of patients is an important element in outcome at ECT. This Scottish group studied the usefulness of giving formal feedback to prescribing clinicians. Most clinicians (79%) thought such feedback was essential but only 47% thought the report influenced practice. Some felt that such reports would be useful for patients.

Patient, treatment and anatomical predictors of outcome in electroconvulsive therapy. (2013). vWaarde J, vOudheusden L, Heslinga O et al., J of ECT 29; 113-121.

Outcome was assessed by use of the MADRS score and cognitive side-effects by use of the MMSE in this clinical trial of 83 consecutive patients. Right unilateral ECT at 6 times seizure threshold was the treatment of choice although bilateral ECT at 2.5 times seizure threshold was used for suicidal patients or if bilateral ECT had worked well before (just under half of the study population). Also confounding examination of the effect of treatment modality was the fact that patients not responding to unilateral ECT could be switched to bilateral. Pre treatment MRI scanning did not correlate with outcome. In keeping with Scottish data those patients whose MADRS scored dropped the most had suffered from psychotic depression or had had ECT before. Cognitive outcome was better in patients with a diagnosis of bipolar depression and worse for patients in receipt of concomitant antipsychotic medication or suffering continued depressive symptoms after ECT.

Efficacy of ultrabrief pulse electroconvulsive therapy for depression: a systematic review. (2013). Spaans HO, Kho K. Verwijk et al., J of Affective Disorders; http://dx.doi.org/10.1016/j.jad.2013.05.072.

The authors reviewed published studies that compared ultrabrief and brief pulse ECT and found no evidence that ultrabrief pulse treatment was better than brief pulse or indeed bilateral electrode placement in terms of efficacy.

Poor health related quality of life prior to ECT in depressed patients normalizes with sustained remission after ECT. (2012). McCall WV., Reboussin D., Prudic J et al. Journal of Affective Disorders; http://dx.doi.org/10.1016/j.jad.2012.10.018.

Health related quality of life scores (HRQOL) are diminished in patients with major depressive disorder, especially those who are prescribed ECT. This large study of over 200 patients concluded that those patients who achieved remission after ECT could expect a quality of life indistinguishable from a healthy population. However only a minority of patients achieved sustained remission.

A comparison of ECT dosing methods using a clinical sample. (2012). Bennett D, Perrin J, Currie J et al., Journal of Affective Disorders; doi:10.1016/j.jad.2012.02.033.

The Aberdeen group determined the seizure threshold of 62 patients and these were then used to calculate how many patients would have received effective treatment at first stimulation if a half-age or fixed dose regime had been used. Only 19.4% of patients on a half-age schedule compared to 61.3% on a high fixed dose regime would have received effective treatment. The authors suggest starting with a small dose of 50mC to mitigate against cognitive side-effects in patients with low seizure thresholds.

Efficacy of electroconvulsive therapy in bipolar versus unipolar major depression: a meta-analysis. (2012). Dierckx B, Heijnen WT, van den Broek WW et al., Bipolar Disorders; 14:146-150.

Antidepressant drugs are more effective in unipolar compared to bipolar depression. The authors carried out a systematic review of six studies and concluded that the overall remission rate following ECT was 50.9% for unipolar depression and 53.2% for patients with bipolar depression.

A comparison of brief pulse and ultrabrief pulse electroconvulsive stimulation on rodent brain and behaviour. (2012). O’Donovan S, Kennedy M, Guinan B et al., Progress in Neuro-psychopharmacology and Biological Psychiatry; doi:10.1016/j.pnpbp.2011.12.012.

The researchers compared sham ECS with ECS using brief pulse (0.5ms) and ultrabrief pulse (0.3ms). Although the seizures produced by both active treatments were indistinguishable it was only the group that received brief pulse ECS that improved significantly compared to controls.

Long term strategies in major depression. A 2-year prospective naturalistic follow-up after successful electroconvulsive therapy. (2012). Martinez-Amoros E, Cardoner N, Soria V et al., Journal of ECT; 28:92-97.

This was a naturalistic study over two years of 127 patients who received either continuation drug treatment or a combination of drug treatment and ECT as maintenance therapy after successful ECT. Both groups did well and the authors suggest that the number of depressive episodes in the two years prior to remission and the duration of the index episode are factors to take into account when considering vigorous maintenance strategies.

Comparing efficacy of ECT with and without concurrent sodium valproate therapy in manic patients. (2012). Jahangard L, Haghighi M, Bigdelou G et al., Journal of ECT; 28: 118-123.

This double blind randomised trial compared the effects of ECT with and without continuation of sodium valproate in 42 manic patients undergoing ECT. All patients improved as evidenced by a reduction in the Young Mania Rating Scale and the Clinical Global Impression of Change. There was no difference between the groups in terms of length of treatment course required or efficacy of ECT and so results were inconsistent with APA guidelines to discontinue anticonvulsant drugs prior to ECT.

Retrospective study of continuation electroconvulsive therapy in 50 patients. (2010). Waarde J, Wielaard D, Wijkstra J et al. Journal of ECT; 26;299-303

This was a retrospective study of the case-notes of 50 patients who had undergone c-ECT at a rate of between once weekly to once every 4-6 weeks. Frequency of ECT was judged according to clinical presentation but increased interval correlated with length of seizure. Doses of electricity were higher at the end of the c-ECT compared to the start but seizure threshold measurement was not repeated.

The efficacy of ultrabrief-pulse (0.25 millisecond) versus brief-pulse (0.50 millisecond) bilateral electroconvulsive therapy in major depression. (2011). Niemantsverdriet L, Birkenhager T & van den Broek W. Journal of ECT; 27;55-58.

There was no difference in outcome measured by the Hamilton Depression Rating Scale in this retrospective study of 65 patients undergoing ECT between 2002 and 2008 and using the different pulse widths referred to above.

Effects of 3 different stimulus intensities of ultrabrief stimuli in right unilateral electroconvulsive therapy in major depression: A randomised, double-blind pilot study.(2011). Quante A., Luborzewski A., Brakemeier E. Journal of Psychiatric Research; 45; 174-178

This was a prospective study of a total of 41 patients. The authors conclude that giving RUECT at 4 times seizure threshold was as effective as 7 times and 10 times threshold and that the higher doses resulted in significantly more impairments on the Verbal Learning Memory Recognition Test.

Episode length and mixed features as predictors of ECT nonresponse in patients with medication-resistant major depression. (2011). Perugi G., Medda P., Zanello S. et al. Brain Stimulation; doi:10.1016/j.brs.2011.02.003.

This prospective study compared the outcome of a total of 208 patients with treatment resistant major depression, bipolar I and bipolar II disorders who received bilateral ECT on a twice weekly basis. 64% of patients responded to treatment as evidenced by a 50% reduction in Hamilton Depression rating scale or a 1 or 2 on the Clinical Global Impression of Change scale. Non response was associated with bipolar disorder, less severe depressive symptomatology and longer duration of illness.

Randomised comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: Clinical efficacy.(2008). Sienaert P et al. Journal of Affective Disorders; 2008.11.001.

This small study showed no difference in cognitive side-effects or eventual outcome although unilateral ECT appeared to work faster than bifrontal. Cognitive side-effects were measured using the MMSE. The authors concede that more research needs to be carried out using different machine parameters before new treatment methods are adopted into clinical practice. The article contains a useful summary of studies that have reported on bifrontal and ultra brief pulse ECT.

Response to ECT in bipolar I, bipolar II and unipolar depression. (2009). Medda et al. Journal of Affective Disorders; 2009.01.014.

This prospective study compared outcome at ECT in three groups of patients. All responded well but the unipolar group showed the best response and bipolar patients tended to exhibit residual psychotic symptoms.

The origins of electroconvulsive therapy: Prof Bini’s first report on ECT. (2009). Faedda et al. Journal of Affective Disorders; 2009.01.023.

The authors translate Professor Bini’s original report on ECT to celebrate the 70^th anniversary of electrically induced seizure therapy.

Convulsive therapy turns 75. (2009). Gazdag et al. BJPsych.; 194, 387-388.

This editorial describes the work of Laszlo Meduna who is accredited with being the first psychiatrist to induce seizures for the treatment of mental illness. He did this, initially by use of camphor then by cardiazol injections in the belief that people with schizophrenia did not suffer from epilepsy. He concluded that cardiazol accelerated remission rate in acute cases andthis accorded with other observation at the time that the main indication for ECT was affective disorder.

The difficult-to-treat electroconvulsive therapy patient – strategies for augmenting outcomes.(2009). Loo C et. al. Journal of Affective Disorders; 2009.07.011.

The authors suggest ways to improve efficacy at ECT by concomitant use of antidepressant medication or the use of techniques aimed at reducing seizure threshold. They are careful to point out that the level of evidence for any of the techniques is at present preliminary.

Effect of concomitant pharmacotherapy on electroconvulsive therapy outcomes.(2009). Sackeim H. et al. Arch.Gen.Psych.Vol. 66(no7); 729-737.

Usual practice in the USA has been to stop antidepressants prior to ECT; this differs from practice in the UK where antidepressant medication is often continued. Sackeim’s group looked at the efficacy of ECT in combination with either venlafaxine or nortriptyline compared to placebo and found that both antidepressants enhanced the antidepressant effect and had different effects on cognitive function. The group also reports that high dose unilateral ECT was superior to bilateral and resulted in less severe amnesia.

Is baseline medication resistance associated with potential relapse after successful remission of a depressive episode with ECT? Datafrom the Consortium for Research on Electroconvulsive Therapy (CORE) (2009). Rasmussen K et al. J Clin Psychiatry. Vol 70 (2); 232-237.

The authors used the data from this large multi-centre trial to examine whether medication resistance, a common indication for ECT, was associated with relapse within the first week following successful treatment. They found that 31% of medication resistant patients relapsed compared to 10% of those not having at least one antidepressant trial pre ECT.

Sham electroconvulsive therapy studies in depressive illness.(March 2009). Keith Rasmussen. Journal of ECT; 25:54-59.

A review of the double blind placebo controlled trials (real vs sham ECT) carried out in the 1970s and 1980s that have formed the basis for the Department of Health review and subsequent NICE guidelines on ECT. In addition the question has been posed about the people who responded to sham ECT, could these people be classified as a depressive subtype by virtue of their placebo response? The author cautions further researchers into other physical therapies to be aware of the strength of the placebo response.

Electroconvulsive therapy, practice and evidence. (2010). Scott AIF. B JPsych; 196,171-172.

An editorial on the randomised controlled trial (described below) from the editor of the second edition of the UK ECT Handbook. Dr Scott summarises the evidence and concludes that there is no ideal electrode placement but instead choice should be based on clinical considerations and the likelihood of cognitive side-effects.

Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial. (2010). Kellner CH, Knapp R, Husain MM et al. BJPsych; 196, 226-234.

This multi-centred, double blind, controlled trial was carried out over five years and involved 230 people, comparing the differences between bilateral (bitemporal), unilateral and bifrontal ECT in terms of effectiveness and cognitive side-effects. Standard dosing schedules were used and each form of treatment was effective. However, bilateral treatment resulted in faster improvement leading to the recommendation to use this method in cases of clinical urgency. Bifrontal treatment did not confer benefit compared to bilateral ECT in respect of cognitive side effects.

Influence of age on the efficacy of electroconvulsive therapy in major depression: a retrospective study. (2010). Birkenhager T. K., Pluijms EM, Ju MR et al.,
Journal of Affective Disorders; 2010.02.131

This review of the case notes of 186 patients, over two sites, who were treated with bilateral ECT concluded that age had no effect on the efficacy of ECT.

Outcomes of 1014 naturalistically treated inpatients with major depressive episode (2009). Seemuller F, Riedel M, Obermeier M. J.euroneuro.2009.11.011.

This was a large multicentre prospective study following the outcome of treatment in over one thousand patients over a four year period. Response, as defined as at least a 50% reduction in HAMD-17 score was achieved in 68.9% and remission (a HAMD-17 total score of less than 8) was achieved in 51.9% of patients adding to the evidence for effectiveness of ECT in a clinical setting. Diagnosis, concomitant medication and demographic details are included.

Relative ineffectiveness of ultrabrief right unilateral versus bilateral electroconvulsive therapy in depression. (2009). McCormick LM, Brumm M, Benede A et al., Journal of ECT; 25:238-242

This was a retrospective case note review of 56 patients, comparing outcome from ultra-brief right unilateral at 6 times and bilateral ECT at 2.5 times seizure threshold. 46% of patients in the unilateral group were switched to bilateral ECT because of lack of efficacy or trouble with seizure induction and the unilateral group required a significantly longer course of treatment to reach response. The authors suggest that increased risk of short term memory impairment should be discussed at the outset if bilateral ECT is chosen in view of apparently superior effectiveness.

Randomised comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: Clinical efficacy. (2008). Sienaert P et al. Journal of Affective Disorders; 2008.11.001.

Response to ECT in bipolar I, bipolar II and unipolar depression. (2009). Medda et al. Journal of Affective Disorders; 2009.01.014.

The origins of electroconvulsive therapy: Prof Bini’s first report on ECT. (2009). Faedda et al. Journal of Affective Disorders; 2009.01.023.

The authors translate Professor Bini’s original report on ECT to celebrate the 70th anniversary of electrically induced seizure therapy.

Convulsive therapy turns 75. (2009). Gazdag et al. BJPsych.; 194, 387-388.

This editorial describes the work of Laszlo Meduna who is accredited with being the first psychiatrist to induce seizures for the treatment of mental illness. He did this, initially by use of camphor then by cardiazol injections in the belief that people with schizophrenia did not suffer from epilepsy. He concluded that cardiazol accelerated remission rate in acute cases and this accorded with other observation at the time that the main indication for ECT was affective disorder.

The difficult-to-treat electroconvulsive therapy patient strategies for augmenting outcomes. (2009). Loo C et al. Journal of Affective Disorders; 2009.07.011.

Effect of concomitant pharmacotherapy on electroconvulsive therapy outcomes.(2009). Sackeim H. et al. Arch.Gen.Psych.Vol 66(no7) 729-737.

Is baseline medication resistance associated with potential relapse after successful remission of a depressive episode with ECT? Data from the Consortium for Research on Electroconvulsive Therapy (CORE). (2009) Rasmussen K. et al. J Clin Psychiatry, Vol 70 (2); 232-237.

Sham electroconvulsive therapy studies in depressive illness. (March 2009). Keith Rasmussen. Journal of ECT; 25:54-59.

The effectiveness of electroconvulsive therapy in treatment-resistant depression: a naturalistic study. June 2008. Khalid N et al. Journal of ECT; 24:141-145.

This group from Cardiff analysed the results of 38 patients receiving ECT for treatment resistant depression. 65.8% responded as evidenced by at least a 50% fall in Hamilton Rating Scale for Depression (HRSD), 53.3% achieved remission – HRSD less that 10. There was no correlation between the number of unsuccessful drug trials and response to ECT.

DSM melancholic features are unreliable predictors of ECT response: a CORE publication. Fink M et al., September 2007. Journal of ECT; 23:139-146

Contrary to expectations this multi-hospital collaborative study of 489 patients between 1997 and 2005 failed to show any correlation between melancholic symptoms and response to ECT

Data management and design issues in an unmasked randomised trial of electroconvulsive therapy for relapse prevention of severe depression: the Consortium for Research in Electroconvulsive therapy trial. Rasmussen K et al. December 2007. Journal of ECT; 23:244-250.

Another report from the CORE multi-hospital study, this time describing the methodology and difficulties faced in a long term study of relapse prevention after ECT. These include: being unable to blind raters, difficulty recruiting depressed patients into a long-term study, undertaking a long-term study of a treatment that causes memory impairment and enrolling patients to receive a treatment associated with stigma.

Open trial on the efficacy of right unilateral electroconvulsive therapy with titration and high charge. Rosa M A et al. December 2006. Journal of ECT:22:237-239.

This was an open study of 30 patients who were given right unilateral ECT at 6 times seizure threshold. Changes in pulse frequency were used to increase the total charge delivered. There was a clinical improvement in 53.3% of patients as evidenced by a 50% reduction in Hamilton Depression Rating Scale. 4 of the 7 non-responders who subsequently received bilateral ECT responded to this treatment. The authors suggest beginning with RUECT and switching to BECT if no response is achieved.

Bifrontal versus right unilateral and bitemporal electroconvulsive therapy in major depressive disorder. Ranjkesh F, Barekatain M & Akuchakian S. Journal of ECT 2005;21(4):207-210.

This was a small double blind study of 39 patients comparing bifrontal (1.5x ST), bitemporal (just above ST) and right unilateral (4x ST) ECT. There was no significant difference in efficacy as measured by a drop in the Hamilton Rating Scale. The bitemporal group showed a significantly lower score in standard mini mental state examination one day after the 8th ECT.

Influence of episode duration of major depressive disorder on response to electroconvulsive therapy. Pluijms E. et al. Journal of Affective Disorders; 90(2006)233-237.

This retrospective review of the records of 56 consecutive patients undergoing ECT for the treatment of major depressive disorder concluded that there was no correlation between length of illness and response to ECT.

Recent developments and current controversies in depression. Ebmeir C, Donaghey C, Steele J.D. Lancet 2006; 367:153-67.

This is a review article, which summarises the causes and associations of depression and describes established and more recent experimental treatments, both psychological and physical. The authors conclude that ‘ECT remains the most effective treatment for treatment of depression especially if it presents with psychotic symptoms’.

ECT for treatment resistant schizophrenia: a response from the Far East to the UK NICE report. Chanpattana W, Andrade C. Journal of ECT 2006; 22(1)4-12.

The authors conducted a review of the literature from Thailand and concluded that, contrary to the recommendations from the National Institute for Clinical Excellence (NICE), there was in fact sufficient evidence for the efficacy of ECT in the short term relief of psychotic symptoms in treatment resistant schizophrenia The paper lists evidence for and shortcomings of research carried out pre and post 1980.

Bifrontal versus right unilateral and bitemporal electroconvulsive therapy in major depressive disorder.Ranjkesh F, Barekatain M & Akuchakian S. Journal of ECT; 2005;21(4):207-210

>This was a small double blind study of 39 patients comparing bifrontal (1.5x ST), bitemporal (just above ST) and right unilateral (4x ST) ECT. There was no significant difference in efficacy as measured by a drop in the Hamilton Rating Scale. The bitemporal group showed a significantly lower score in standard mini mental state examination one day after the 8th ECT.

Influence of episode duration of major depressive disorder on response to electroconvulsive therapy. Pluijms E et. al. Journal of Affective Disorders; 90(2006)233-237.

Recent developments and current controversies in depression. Ebmeir C, Donaghey C, Steele J.D., Lancet 2006; 367:153-67.

ECT for treatment resistant schizophrenia: a response from the Far East to the UK NICE report. Chanpattana W, Andrade C. Journal of ECT 2006;22(1)4-12.

Prediction of response to ECT with routinely collected data in major depression. Vreede I, Burger H, van Vliet I. Journal of Affective Disorders; 86 (2005) 323-327.

This was a case note study of 53 patients over a 4 year period to try and determine factors predicting poor outcome as defined by less that 50% reduction in Hamilton Rating Scale for Depression. Poor outcome was recorded in 58%. Predictors of a poor response were: personality disorder, age <65years, previous treatment resistance and psychotic depression and the authors suggest the use of these factors to construct an index score to predict poor outcome. The association between poor outcome with age < 65 and personality disorder was statistically significant.

Predicting efficacy of electroconvulsive therapy in major depressive disorder. Tsuchiyama K et al. Psychiatry and Clinical Neurosciences (2005), 59, 546-550.

A small study of 24 patients with the conclusion that outcome was better if prior treatment with antidepressant was inadequate. There was no correlation with other demographic or clinical variables. The authors noted significant correlation between improvement after 3 ECTs and good eventual outcome.

Bifrontal electroconvulsive therapy in the elderly. Little J et al.June 2004. Journal of ECT; 20:139-141.

The authors present a retrospective review of bifrontal ECT given to 14 patients, mean age of 74 years over a two year period. 86% responded unequivocally,according to case note information, after a mean of 8.5 treatments. 35% of patients were noted to experience cognitive side-effects. Individual seizure threshold was measured and doses increased according to length of seizure and EEG characteristics.

Comparison of clinical efficacy and side effects for bitemporal and bifrontal electrode placement in electroconvulsive therapy. Bakewell C et al. September 2004. Journal of ECT; 20:145-153.

This was a retrospective review of the case notes of 76 patients over a 6 year period. The authors conclude that a bilateral electrode placement was more effective but associated with a modestly greater rate of cognitive side-effects than bifrontal.

One-year outcome of elderly inpatients with major depressive disorder treated with ECT and antidepressants. Huuhka M et al. September 2004. Journal of ECT; 20:179-185.

51 elderly patients were followed up for one year; 30 after ECT and 21 after antidepressant treatment. Both groups had responded well to the initial treatment phase but the relapse rate for both was high with an average of 41% requiring re-hospitalisation - 41% in the ECT group, 38% in the antidepressant group.

Effects of ECT stimulus parameters on seizure physiology and outcome. Kotresh S et al. Journal of ECT; March 2004, 20(1):10-12.

This group from Bangalore found that reducing seizure frequency had no effect on stimulus parameters and outcome at ECT. The pulse width and current were kept constant therefore the pulse train increased proportionately in the lower frequency group. Reduced seizure frequency was associated with a lower seizure threshold and a smaller number of non-convulsive seizures.

Efficacy of ECT in depression: A meta-analytic review. Pagnin D et al. Journal of ECT; 20(1):13-20

This meta-analysis from Italy reaches the same conclusion as that of the Department of Health study published in the Lancet of March 2003, that ECT is superior to simulated ECT, antidepressant treatment or placebo antidepressants.

Right Unilateral Electroconvulsive Therapy at six times Seizure Threshold. Little J.D., et. al. Australian and New Zealand Journal of Psychiatry. December 2003. 37(6):715-719.

This was a retrospective review of 21 patients given right unilateral ECT at doses exceeding 388 mC. 80% of patients responded after a mean of 7 treatments. Cognitive side-effects were noted in 21%. Long term follow up showed a relapse rate of 52% despite continuation pharmacotherapy.

Seizure Threshold in ECT: Effect of Stimulus Pulse Frequency. Girish K et al. Journal of ECT; September 2003, 19(3):133-135.

The authors found that the use of low stimulus pulse frequency (50 cf 200 pulses per second) was more efficient at inducing seizures in a series of 24 patients receiving bilateral ECT. In other words the seizure threshold was induced at a lower total dose of electricity when using the lower pulse frequency.

A Meta-Analysis of Electroconvulsive Therapy Efficacy in Depression. King Han Kho et. al. Journal of ECT; September 2003, 19(3):139-147.

Fifteen studies were used to address questions of efficacy, speed of response and variables to predict outcome. As expected ECT was found to be superior to antidepressants and sham ECT. No evidence was found for a superior speed of action of ECT and brief pulse machines were as effective as sine wave. Depressive illness with psychosis was predictive of a good outcome.

Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. The UK ECT Review Group. Lancet March 2003;361:799-808.

This extensive systematic review was carried out at the request of the Secretary of State for Health and was funded by the Department of Health in England. Results of analyses are plotted in easy to follow graphic format. The main conclusions were that ECT is more effective than drug treatments in depressive illness and that bilateral ECT is more effective than unilateral. (however the review was unable to take account of more recent research on higher dose unilateraltreatment) In general there is a trade off between efficacy of treatment and cognitive side-effects consequently ECT should be tailored to take account of the clinical state.

Long-Term Maintenance ECT: A Retrospective Review of Efficacy and Cognitive Outcome. Russell J. et al., Journal of ECT; March 2003; 19(1):4-9

This was a review of the 43 patients given maintenance(continuation) ECT over year 2000 at the Mayo Clinic, Minnesota. The authors concluded that continuation ECT was efficacious, well tolerated and had reduced the need for hospitalisation in this chronically depressed, medication resistant population.

Continuation and Maintenance ECT in Treatment Resistant Bipolar Disorder. Vaidya N Mahableshwarker A & Shahid R. Journal of ECT; March 2003; 19(1):10-16.

A search of Medline produced 12 publications, half of which were case reports and case studies were performed on the 13 patients receiving maintenance (continuation) ECT at a Veterans treatment centre. As in the preceding article, the authors conclude that continuation ECT is effective and is underused in the treatment of mood disorder.

Electroconvulsive therapy and newer modalities for the treatment of medication-refractory mental illness.[Review - 11 Refs] Rasmussen KG, et. al, Mayo Clin Proc 2002 Jun; 77(6):552-6

Efficacy of continuation ECT and antidepressant drugs compared to long-term antidepressants alone in depressed patients. Gagne GG Jr, et. al., Am J Psychiatry 2000 Dec;157(12):1960-5.

Relationships between Seizure Duration and Seizure Threshold and Stimulus Dosage at Electroconvulsive Therapy: Implications for Electroconvulsive Therapy Practice. Chung K. Oct 2002. Psychiatry & Clinical Neurosciences, Vol 56 Issue 5, 521-527.

This retrospective study of 54 patients showed a negative correlation between seizure length and stimulus intensity adding to the evidence that the dosing schedule should not be based on measurement of the seizure length. (Current evidence suggests that bilateral ECT should be given at 1.5-2 x seizure threshold, unilateral ECT at 5-8 x seizure threshold)

Electroconvulsive Therapy for Schizophrenia. [Update of Cochrane Database Syst Rev. 2000;(2):CD000076; 10796292]. Tharyan P & Adams CE. Cochrane Database of Systematic Reviews. (2):, 2002.

This review includes 24 trials with 46 reports. The author concluded that there was some limited evidence to support the use of ECT, particularly combined with antipsychotic for those with schizophrenia who showed limited response to medication alone.

Augmentation of Seizure Induction in Electroconvulsive Therapy: A Clinical Reappraisal. Datto C. et. al. Journal of ECT; 18(3):118-125.

This review analyses data on the safety and efficacy of seizure augmentation techniques. The authors conclude that hyperventilation and the use of etomidate or other agents compare favourably with caffeine. They acknowledge the importance of the seizure threshold and stimulus intensity rather than the seizure length and go on to suggest that investigation of pharmacological augmentation could provide further insights into seizure efficacy.

Markedly Suprathreshold Right Unilateral ECT Versus Minimally Suprathreshold Bilateral ECT: Antidepressant and Memory Effects. Vaughn McCall V et. al., Journal of ECT; 18(3):126-129.

This study of 77 patients divided into two groups failed to show any significant difference in outcome between bilateral ECT at 1.5 time seizure threshold and unilateral ECT at eight times seizure threshold although the trend for efficacy favoured the bilateral ECT group. The authors acknowledge that numbers studied were small but that both methods were justified as a first line technique.

Stimulus Titration and ECT Dosing. Richard Abrams March 2002. Journal of ECT; 18(1):3-9.

Yet more on the debate about the optimum dosing schedule in this editorial from Abrams. He believes that the research focus on measuring seizure threshold has delayed the production of clinically useful dosing schedules for unilateral ECT. His preference for unilateral ECT is to begin with maximum dose andswitch to bilateral ECT only if the patient does not improve. If bilateral ECT is being used, he advocates use of the 'half-age' method of determining treatment dose.

Stimulus Titration and ECT Dosing- commentaries. March 2002. Journal of ECT; 18(1):10-15.

Keith Rasmussen points out that for approximately one third of patients a 'fixed' or 'age related' dose will represent either an overdose or an inadequate dose of electricity.

Max Fink agrees with Abrams that there is no clinical role for titration based dosing and that bilateral ECT, given according to an age based schedule, should be accepted as norm and research efforts should concentrate on finding EEG correlates of clinical improvement.

Richard Weiner presents the view that the debate on choice of stimulus is 'the subject of much opinion and little data'. The American Psychiatric Association Committee has recently recommended the use of either formula based or dose titration based techniques. Weiner believes that it is increasingly likely that 'some degree of matching stimulus to patient' will represent the most cost-effective option.

Right Unilateral and Bifrontal Electroconvulsive Therapy in the Treatment of Depression: a Preliminary Study. Heikman P et al. March 2002. Journal of ECT; 18(1):26-30.

This is a small study of 24 patients comparing the clinical effects of three treatment modalities: high dose unilateral (x5), moderate dose uni-lateral (x 2.5) and just above threshold bifrontal (x1) ECT. The high dose unilateral ECT was associated with a significantly faster response but the authors feel that studies of higher than threshold bi-frontal ECT eg at least 1.5 times seizure threshold are warranted.

Long-term outcome after ECT for catatonic depression. Swartz C et al. Journal of ECT; September 2001, 17(3): 180-183.

Further evidence to support the view that maintenance treatment is required to prevent relapse following a course of ECT. In this group of 19 patients, 10 out of 13 on maintenance 'anti-melancholic' therapy were still well whereas none of the 6 patients on limited continuation therapy had as good an outcome. Three patients in this latter group had died of acute cardiopulmonary conditions.

ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. Petredes G et al. Journal of ECT; December 2001. 17(4): 244-253.

This a report from the Consortium for Research in ECT (CORE) describing the first phase of a National Institute for Mental Health supported study looking at the effectiveness of episode and maintenance ECT. 253 depressed patients were divided into 'psychotic' and 'non-psychotic' groups. Remission rates were 95% for the 'psychotic' group and 83% for the 'non-psychotic' group, leading the authors to suggest that there are differing biological mechanisms for each type of depression.

Is electroconvulsive therapy effective for the depressed patient with comorbid borderline personality disorder? DeBattista C. and Mueller K. June 2001, Journal of ECT; 17(2):91-98.

A review of 13 original reports, limited by methodological weaknesses, which concludes that ECT treats DSM axis I depressive illness but does not alter any underlying personality traits.

Inverse relation between stimulus intensity and seizure duration: implications for ECT procedure. Frey R et al. June 2001. Journal of ECT; 17(2):102-108.

A retrospective analysis which adds weight to the observation that seizure length is an unreliable guide to treatment adequacy. There was a negative correlation between dose above seizure threshold and length of seizure in the group receiving ECT according to an age related treatment schedule. The authors caution against frequent high dose re-stimulation based on observations of seizure length.

ECT: A different look at prescription. Gangadhar B. & Bolwig T. page 399.

Relapse prevention in major depressive disorder after successful ECT: a literature review and a naturalistic case series. Wiljkstra et al. page 454. both in the December 2000 Acta Psych. Scand.,102, 6.

An editorial and review on the possible role of maintenance / prophylactic ECT is discussed in particular the best continuation treatment for ECT-treated, medication resistant patients with depressive disorder.

Seizure threshold estimation by formula method: a prospective study in unilateral ECT. Girish K et al. September 2000, Journal of ECT; 16(3):258-262.

Seizure threshold was measured by titration in 80 patients, a formula was worked out then applied in a validation phase to 30 patients. The formula based estimate would have been successful in 73% but because this would have overestimated the seizure.

Prediction of the utility of a switch from unilateral to bilateral ECT in the elderly using treatment 2 ictal EEG indices. Krystal A et. al. December 2000, Journal of ECT; 16(4):327-337.

Lack of post ictal suppression after the second ECT may predict those patients who will not respond to UL ECT and should therefore be switched to the BL treatment modality. An early study which needs replication.

The development and retrospective testing of an electroencephalographic seizure quality-based stimulus dosing paradigm with ECT. Krystal a et al. December 2000, Journal of ECT; 16(4):338-349.

A preliminary study supporting the role of EEG models in helping ECT clinicians to maintain maximum theraputic efficacy whilst minimising cognitive side-effects. Controlled prospective studies are needed before conclusions can be reached.

Electrical dose and seizure threshold: relations to clinical outcome and cognitive effects in bifrontal, bitemporal and right unilateral ECT. Delva N et al. December 2000, Journal of ECT; 16(4):361-369.

The study of 59 patients reports no differences in seizure length between groups and no correlation between seizure length and increase in seizure threshold or outcome. The group concluded that bifrontal ECT offered the best ratio of benefits to side-effects if given at threshold level.

Efficacy and cognitive side-effects of right unilateral electroconvulsive therapy. Chee Ng et. al. December 2000, Journal of ECT; 16(4):370-379.

A study from Australia supporting the view that UL ECT at 2.5 times seizure threshold may not be efficacious.

A prospective, randomised, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Sackeim H et al. Arch Gen Psychiatry, May 2000, vol 57, 425-434.

The authors report that markedly suprathreshold (ie5xST) RUL ECT is as effective as BL ECT and without the cognitive side-effects but numbers in each treatment arm of this study are too small to be conclusive.

Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy. McCall WV et al. Arch Gen Psychiatry, May 2000, vol 57, 438 - 444.

Titrated moderately suprathreshold RUL ECT produced a lower antidepressant response but fewer cognitive side-effects than fixed dose RUL ECT. Also the higher above ST (up to x12) the more the antidepressant effect but the more the cognitive side-effects.

High dose right unilateral ECT. Editorial by Charles H Kellner, September 2000, Journal of ECT, vol 16 no 3, 209-210.

A question, that for equivalent efficacy with RUL ECT the dose above seizure threshold may have to be so high as to cause more side-effects than with low dose BL ECT.

The effect of repeated bilateral electroconvulsive therapy on seizure threshold. Scott AIF and Boddy H, September 2000, Journal of ECT, Vol 16, no 3,244-251.

An Edinburgh study of 28 patients showing on average a 22.8% increase in seizure threshold after 6 treatments. There was no correlation with clinical outcome or change in seizure length and the seizure threshold did not change in 54% of patients.

Determinants of seizure threshold in ECT: benzodiazepine use, anaesthetic dosage and other factors. Boylan et al. March 2000, Journal of ECT, 16(1):3-18.

This paper which includes a literature review reports a 35 fold variation in seizure threshold for RUL ECT. Age was the strongest predictor of ST at only 13% variance.

Relapse of depression after ECT: a review. Bourgon L., Kellner C., March 2000, Journal of ECT 16(1):19-31.

This review concludes that the relapse rate without follow-up treatment is in excess of 50% within six months. Medication resistance pre-ECT was shown to predict relapse in two studies.

Brandon S., Cowley P. ,McDonald C. et. al. (1984), Electroconvulsive therapy - results in depressive illness. Leicestershire Trial, BMJ, 288, 23-25.

Freeman C.P.L., Basson J., Crighton A., (1978), A double-blind controlled trial of ECT and simulated ECT in depressive illness. , Lancet, i, 738-740.

Johnstone E.C., Deakin D.F., Lawley P., et. al. (1980), The Northwick Park ECT Trial. , Lancet ii, 1317-20.

Robertson C. (1985),Effectiveness of ECT in a clinical setting. M. Phil Thesis, University of Aberdeen.

Robertson C., Eagles J., (1997), Review of ECT prescription and outcome in depression. , .Psychiatric bulletin, 21,498-500.

Sackeim H.A. (1998),The use of electroconvulsive therapy in late life depression. , Geriatric Pharmacology, third edition. Ed by Salzman C Baltimore. pp 262-309.

West E. (1981),Electroconvulsive therapy in depression - A double blind controlled trial. , .BMJ, 282, 355-357.

References

Evidence for efficacy & treatment modality