2. Safety and cost-benefit analysis

• The safety of electroconvulsive therapy in patients with prolonged QTc intervals on the electrocardiogram. (2011) Pullen S, Rasmussen K, Angstman E et al. J of ECT; 27: 192-200
  
  The charts of 1437 patients were reviewed and data produced supported a connection between baseline QTc interval and relative risk for developing a cardiac related side-effect.

• Safety of electroconvulsive therapy in patients with a history of heart failure and decreased left ventricular systolic function. (2011) Rivera F, Lapid M, Sampson S et al. J of ECT 27: 207 – 213.
  

  There was a successful outcome in the 35 patients with cardiac failure and decreased left ventricular funtion who underwent ECT over a 14 year period. Prophylactic treatment with beta blockers was used if patients were hypertensive or suffering from tachycardia pre-treatment.

• Influence of age on effectiveness and tolerability of electroconvulsive therapy. (2010) Damm J, Eser D, Schule C et al. J of ECT;26:282-288
  
  The authors reviewed the case notes of 380 patients and classified elderly as those over 60yrs. This group, accounting for 30% of the total, were more likely to be suffering from a mood disorder rather than schizophrenia. There was no relationship between improvement, as evidenced by the GCI scale, and age although there were age related effects on the three neurophysiological measures recorded (post suppression index, convulsive energy index, convulsion concordance index). Higher severity of illness at admission and female sex correlated with improvement. There was a significant increase in the prescription of drugs for medical conditions in the elderly group and increased rates of transient disturbance of cognitive and cardiac function were also observed.
• ECT efficacy and treatment course: a systematic review and meta-analysis of twice vs thrice weekly schedules. (2011) Charlston F, Siskind D, Doi S et al. J.Affect.Disorder, doi:10.1016/j.jad.2011.03.039.
  
  The authors reviewed literature to 2009 analysing outcome of a total of 214 patients. Twice weekly ECT was associated with similar efficacy to thrice weekly, requiring fewer treatments but over a longer time frame.
• Comparison of electroconvulsive therapy (ECT) with or without anti-epileptic drugs in bipolar disorder. (2010) Virupaksha H., Shashidhara B., Thirthalli J et al. Journal of Affective Disorders 127;66-70
  
  This was a study of the case records of 79 patients on anti-epileptic drugs (AED) for bipolar compared to 122 controls. Both groups responded well to ECT but the AED group required a significantly greater number of sessions and a longer period in hospital, presumably in part because of the associated higher incidence of failed treatments. The AED group had a significantly greater proportion of males, a longer duration of illness and a higher degree of co-morbidity.
• ECT efficacy and treatment course: A systematic review and meta-analysis of twice versus thrice weekly schedules. (2011) Chalrson F., Siskind D., Doi S et al. Journal of Affective Disorders. Doi:10.1016/j.jad.2011.03.0339.
  
  This epidemiological study supports the routine use of twice weekly ECT which was associated with equal efficacy to thrice weekly treatment Although patients in this category needed fewer treatments they appeared to require a longer period of hospitalisation.
• Electroconvulsive therapy and its place in the management of depression. (2011) Singhal A. Progress in Neurology and Psychiatry; 19-26.
  
  A review article that includes a brief history, procedure at ECT and a description of current practice in the UK. The Royal College of Psychiatrists’ guidelines are summarised and compared to the NICE guidance that was issued in 2003. The author believes that the key to success is in the careful selection of patients and lists the most common clinical indications for treatment.

• A critical examination of bifrontal electroconvulsive therapy: clinical efficacy, cognitive side-effects and directions for future research. (December 2008)

Crowley K et al. J of ECT; 24:268-271.

• Effect of concomitant pharmacotherapy on electroconvulsive therapy outcomes. Short-term efficacy and adverse effects. (2010) Sackeim HA, Dillingham EM, Prudic J et al. Arch Gen Psychiatry;66(7):729-737.
  
  This was a prospective, randomised, triple blind, placebo controlled trial over a 5 year period in three hospitals comparing the outcome of high dose unilateral with bilateral ECT, with or without nortriptyline or venlafaxine. Patients receiving concomitant antidepressants had a better outcome and unilateral ECT was as efficacious as bilateral and with less severe cognitive side-effects.
• Cognition in elderly patients receiving unilateral and bilateral electroconvulsive therapy: A prospective, naturalistic comparison. (2009) O’Connor DW, Gardner B, Eppingstall B et al. J.Affect.Disord; doi:10.1016/j.jad.2009.11.022.
  
  The authors reviewed recent studies of ECT in the elderly population and set out to recruit from six centres to study the effects of different treatment modalities. Sixty three patients were involved and the authors concluded that bilateral ECT at 1.5 times seizure threshold was no more effective that unilateral ECT at 3 times threshold and resulted in greater impairment of immediate verbal memory and autobiographical memory.
• A critical examination of bifrontal electroconvulsive therapy: clinical efficacy, cognitive side-effects and directions for future research. (December 2008) Crowley K et al. J of ECT; 24:268-271.
  The authors remind us of the need to develop tests to pick up cognitive side-effects involving frontal lobe function (for example executive function) before concluding that bifrontal ECT offers benefits over the more traditional bitemporal and unilateral electrode placements.
• Strategies to minimise cognitive side-effects with ECT: aspects of ECT technique. March 2008. Joan Prudic, J of ECT. 24:46-51
  
  A nice summary of the factors that contribute to cognitive side effects, namely: electrical waveform, electrode placement, stimulus intensity (dose), frequency and number of treatments.
• Individualised continuation electroconvulsive therapy and medication as a bridge to relapse prevention after an index course of electroconvulsive therapy in severe mood disorders: a naturalistic 3-year cohort study. September 2008. Odeberg H et al, J of ECT; 24:183-190.
  
  The timing of continuation ECT was triggered by signs of relapse in the 41 patients studied. Concomitant medication was recorded. By the end of the three year period the hospital bed days had reduced by 76%
• Efficacy of maintenance electroconvulsive therapy in recurrent depression: a naturalistic study. September 2008. Gupta S et al. J of ECT; 24:191-194
  
  The authors acknowledge the difficulty that UK practitioners now face in the light of the National Institute for Health and Clinical Governance (NICE) guidelines on maintenance ECT. They looked back at the outcome of 19 of their own patients who had been given maintenance ECT ‘ pre NICE’ and concluded that inpatient days fell significantly compared to pre treatment levels.  The improvement was also maintained after stopping treatment
• Anticonvulsants during electroconvulsive therapy: review and recommendations. Sienaert P & Peuskens J. June 2007. J of ECT;23:120-123.
  
  The authors undertook a MEDLINE search for 1985-2006 and concluded that there was no published evidence that suggested a combination of anticonvulsant drugs and ECT either caused increased side-effects or altered outcome. At the time of publication there had been no randomised prospective studies reported.
• Monitoring electroconvulsive therapy by electroencephalogram: an update for practitioners. Scott A. July 2007. Adv in Psychiatric Treatment, vol 13,298-304.
  
  An update on the latest published research on prolonged seizure activity at ECT together with practical tips on assessing the EEG in the clinic. It is not yet possible to examine an individual tracing and make accurate predictions about outcome but the quality of EEG tracings may add to decisions about treatment modality.
• Serum sodium does not correlate with seizure length or seizure thereshold in electroconvulsive therapy. Rasmussen K, Mohan A, Stevens S. September 2007. J of ECT;23:175-176
  
  A study of 207 patients, some of whom had mild abnormalities relating to hypo and hypernatraemia. The numbers were not statistically significant but the authors conclude that whilst it is preferable to correct any biochemical abnormalities that minor changes in serum sodium level did not affect the seizure threshold or seizure length.
• All-cause mortality among recipients of electroconvulsive therapy. Munk-Olsen et al. British Journal of Psychiatry (2007),190,435-439.
  
  The cause of death of 783 patients who had received ECT over a 25 year period was analysed. Patients who had received ECT had a lower overall mortality rate from natural causes but a slightly higher suicide rate, especially in the first 7 days after treatment.
• Health related quality of life following ECT in a large community sample. Vaughn McCall et al. J of Affective Disorders 90 (2006) 269-274.
  
  This naturalistic study of 283 depressed patients assessed both quality of life and cognitive impairment post ECT and at 24 weeks later. Health related factors improved with recovery from depression despite the fact that cognitive impairment was associated with this improvement in the short term.  In contrast, at 24 week follow up improvement in cognitive status was associated with better quality of life. Failure to respond to ECT was not associated with a fall in quality of life relative to baseline.
• Imipramine is effective in preventing relapse in electroconvulsive therapy –responsive depressed inpatients with prior pharmacotherapy treatment failure: a randomised placebo controlled trial. Van den Broek et al. J Clin Psychiatry 67: Feb 2006.
  
  This is a study of 27 patients over a 4 year period who were  given ECT for major depressive disorder. At six month follow up there was an 80% relapse rate on placebo compared to 18% on imipramine. This was despite the fact that most patients (22/27) had failed to respond to a tricyclic antidepressant and 24/27 to lithium augmentation prior to ECT.
• Continuation and maintenance electroconvulsive therapy for the treatment of depressive illness: a response to the National Institute for Clinical Excellence report. Frederikse M, Petrides G, Kellner C. J of ECT 2006;22(1):13-17.
  
  This review of recent literature suggests that continuation ECT is an important option especially for those patients who have responded well to an acute course of ECT. The authors give a description of the methodology used in the Consortium for Research in ECT Group (CORE) study on maintenance ECT, the first large-scale, randomised controlled trial involving ECT and due for publication in the near future.
• Health related quality of life and the practice of electroconvulsive therapy. Rosenquist et al. J of ECT 2006;22(1):18-24.
  
  This review outlines the measures used in health related quality of life (HRQL) studies and summarises HRQL studies looking at ECT, including the study by McCall et al referred to above. The authors conclude that there is an emerging literature which demonstrates the importance of ECT in restoring function and quality of life in depressed patients.
• Is ECT cost-effective? A critique of the National Institute of Health and Clinical Excellence’s report on the economic analysis of ECT. McDonald W. J of ECT 2006;22(1):25-29.
  
  The NICE technology appraisal of ECT concluded that it was cost neutral compared to antidepressant therapy. However this article questions the validity of this conclusion on the grounds that patient groups were not well matched for severity of illness.
• The safety of electroconvulsive therapy and lithium in combination. September 2005. Dolenc T & Rasmussen K. J of ECT. 21(3):165-170.
  
  This was a study of a series of 12 patients whose lithium treatment was continued during ECT without significant complications arising. The authors provide a useful summary of the literature and recommendations include the continued use of lithium if this has previously proved effective as a mood stabiliser or anti-manic, advising that lithium levels should be kept at the lower end of the therapeutic range.
• No brain perfusion impairment at long-term follow-up in elderly patients treated with electroconvulsive therapy for major depression. Navarro V et al. June 2004. J of ECT 20:89-93
Three groups of elderly patients were subjected to SPECT scanning: 1) 14 patients, one year after successful ECT, 2) 22 who were euthymic for one year following pharmacotherapy and 3) 25 age and sex matched controls. No significant differences in brain perfusion were detected.