6th Electroconvulsive Therapy Research Articles

Comparative efficacy and tolerability of different anesthetics in electroconvulsive therapy for major depressive disorder: A systematic review and network meta-analysis

Electroconvulsive therapy (ECT) is one of the most effective treatments for major depressive disorder. Modern ECT is conducted with anesthesia, however, the optimal anesthetic agent for ECT is yet to be understood. This study is aimed to compare the effects of different anesthetic agents on antidepressant efficacy and tolerability in depressed individuals undergoing ECT. We searched MEDLINE, EMBASE, the CENTRAL and PsycINFO for randomized controlled trials from database inception until Nov 13, 2022 (PROSPERO: CRD42022375407). Global and local inconsistencies, heterogeneity and publication bias were assessed. Rankings were calculated with the surface under the cumulative ranking curve. A total of 33 studies involving 1898 patients were enrolled. Remission rates were higher for ketamine anesthesia as compared to adjunctive ketamine and propofol. In terms of ranking, ketamine was found to be first in terms of response/remission rates and depressive scores after the 1st, 3rd and 6th ECT and at the end of ECT session, while a higher incidence of adverse events was also observed. No significant advantage of any anesthetic was revealed for the cognitive function after ECT. In summary, based on current evidence, no specific anesthetic is recommended for ECT anesthesia. However, despite more side effects, ketamine monoanesthesia seems to reveal a potential benefit in improving antidepressant efficacy of ECT, and further studies are needed to investigate the relationship between anesthetic agents and the therapeutic effect of ECT.

Efficacious retrial of electroconvulsive therapy (ECT) after a prolonged seizure in an older adult with a history of post ECT confusion

<h3>Introduction</h3> This is a case of a 77-year-old woman with treatment resistant geriatric major depression who was admitted psychiatrically for the 5th time in 1.5 years. She had a history of intensive psychotherapy and psychotropic medication trials with poor efficacy. She had a history of adverse complication to electroconvulsive therapy (ECT) with prolonged seizure and postictal confusion during her 3rd hospitalization. At her 5th hospitalization, due to poor response to routine psychiatric treatment, ECT was pursued. We discuss challenges in pursuing ECT and outcome of retrial of an acute ECT series, in the context of paucity of similar literature in geriatric depression <h3>Methods</h3> Patient was involuntarily admitted to the Older Adult inpatient Unit due to worsening anxiety and depression with suicidal ideation that began 1 month prior to admission. Patient reported having suicidal thoughts on a daily basis. Patient had been experiencing worsening depression since her husband died 3 years ago, had attempted multiple outpatient treatments including psychotherapy and medications. Patient was psychiatrically hospitalized 4 times prior to the current hospitalization. The patient met criteria for major depressive disorder, recurrent, severe, without psychotic features, generalized anxiety disorder with panic attacks. Patient displayed cognitive deficits with executive dysfunction, impairment with problem solving and planning. For diagnostic clarification, patient received neuropsychiatric testing which revealed a mild neurocognitive disorder with potential contribution of her depression. During her 3rd psychiatric admission, she had received an acute series of electroconvulsive therapy. During her 4^th ECT session,the patient had a prolonged central seizure requiring total 2 mg of midazolam to abort the seizure which eventually lasted 489 seconds. This was followed by prolonged post ECT confusion that lasted for 7 days. Medical workup of any other etiology for her prolonged confusion was negative including EEG, CT head. Eventually confusion resolved and interestingly the patient's depression and anxiety also appeared to be in remission. <h3>Results</h3> With the above history influencing her current admission, we were initially hesitant to start an acute series of ECT, however, with continued treatment refractory depression, ECT was recommended to the patient and the family. Since prolonged seizures are not a contraindication for ECT and due to the patient's good response to ECT, we felt this was an appropriate treatment. Long discussion about risks, benefits and side effects occurred with patient, who signed informed consent for acute ECT. Patient received 6 right unilateral treatments three times a week. Patient also received serial Montreal cognitive assessment (MOCA) testing during her acute series. Patients first moca was 15/30 which increased to a 28/30 over 12 days indicating improvement in cognition with improvement in anxious depression. After 6th ECT, patient was deemed to be in remission and was transitioned to maintenance ECT. Per chart review, patient remains in remission after her 5th ECT treatment. After reviewing the literature we could not find evidence of an efficacious retrial of electroconvulsive therapy after a prolonged seizure in an older adult with a history of post ECT confusion. <h3>Conclusions</h3> ECT is an important treatment modality in the geriatric population indicated for severe major depression (1) While the APA quotes no absolute contraindications to ECT and further research has demonstrated that prolonged seizures or acute cognitive impairment are not relative contraindications either, the patient's history and past experiences with treatment are an important part of developing a treatment plan. (2) We present this case to demonstrate efficacy of retrial of ECT in older adults who experience both a prolonged seizure and negative cognitive effects can be an appropriate treatment plan. <h3>References</h3> 1. Electroconvulsive Therapy in Geriatric Psychiatry A Selective Review. 2. https://www.openanesthesia.org/ect_contraindications/. <h3>Funding</h3> none

Subanesthetic dose of ketamine for the antidepressant effects and the associated cognitive impairments of electroconvulsive therapy in elderly patients-A randomized, double-blind, controlled clinical study.

ObjectivesWe previously confirmed that low‐dose ketamine, as an adjunctive anesthetic for electroconvulsive therapy (ECT) in adult patients with depression, accelerates the effects of ECT and reduces the ECT‐induced learning and memory deficits. This study explored the efficacy and safety of low‐dose ketamine in elderly patients with depression.MethodsElderly patients with depression (N = 157) were randomly divided into two groups: propofol anesthesia group (group P) and propofol combined with ketamine anesthesia group (group KP). Patients in group KP were given low‐dose ketamine (0.3 mg/kg) for each ECT treatment; patients in group P were given the same amount of normal saline. Depressive symptoms and global cognitive functions were assessed using the 24‐item Hamilton Depression Rating Scale and Mini‐Mental State Examination, respectively, at baseline, 1 day after the 1st, 2nd, 4th, and 6th ECT sessions, and 1 day after the end of the ECT course. ECT effects of and complications were recorded.ResultsIn total, 67 patients in group KP and 70 in group P completed the study. After the ECT, the response and remission rates were 82.09% and 73.13%, respectively, in group KP, and 81.43% and 68.57%, respectively, in group P; there was no statistical difference between groups. However, the incidence of cognitive function impairment was lower in group KP (10.4%) than in group P (25.7%), while different electrical dose and seizure duration were required during the course of treatment between the two groups. There was no difference in the complications of ECT between groups.ConclusionsLow‐dose ketamine is safe as an adjunct anesthetic for elderly patients subjected to ECT. It has a protective effect on cognitive function and may accelerate the antidepressant effects of ECT.

TREATMENT PARAMETERS AND RATIONALE FOR THE USE OF ELECTROCONVULSIVE THERAPY FOR THE MANAGEMENT OF TREATMENT-REFRACTORY AGITATION IN ALZHEIMER'S DISEASE

TREATMENT PARAMETERS AND RATIONALE FOR THE USE OF ELECTROCONVULSIVE THERAPY FOR THE MANAGEMENT OF TREATMENT-REFRACTORY AGITATION IN ALZHEIMER'S DISEASE

Early shifts of emotional attention as a possible predictor of remission in patients with depression receiving ECT: Preliminary results of an eye-tracker study

Background Electro-convulsive therapy (ECT) is one of the most effective treatment for treatment resistant depression (TRD) with remission rates of 87% [1] . Despite such a significant clinical effect generally observed after 6 to 20 sessions, ECT is also accompanied by major cognitive side effects and no markers of remission are available to help practitioners deciding to continue or not to deliver ECT sessions. Evidence suggests that early improvements in emotional processing, a commonly observed cognitive deficits in depression, can predict later clinical response to antidepressant [2] . Based on these studies, we hypothesized that early enhancement in emotional processing would predict remission in patients receiving ECT. Methods In an open pilot study, 30 patients with TRD receiving ECT will be enrolled. A free-viewing eye-tracking paradigm will be used to measure preferential attention to positive, negative or neutral faces. In this task patients will have to passively watch 2 pictures of faces (one neutral and one emotional face) presented during 3.5 sec on a computer screen. Eye-gaze patterns and time spend to the affective and to the neutral face will be assessed twice, one time at baseline and one time after the 6th ECT session. Severity of depression will be assessed using the MADRS at baseline, after the 6th and after the last ECT sessions. Results We report preliminary results in 8 patients. At the 6th ECT session, attention to happy faces was improved by 27% after 6 ECT treatments as compared to baseline in future remitters (MADRS Conclusion Early modification at free-viewing eye-tracking paradigm measuring emotional attention could be a predictive marker of remission to ECT in patients with TRD. Further investigation are needed to confirm this hypothesis.

P.2.d.032 Management of postpartum manic episode without cessation of breastfeeding: a longitudinal follow up of drug excretion into breast milk

The use of electroconvulsive therapy (ECT) in treatment of psychiatric disorders is associated with adverse cognitive effects. There is a need to develop a short assessment tool of cognitive functions during the course of ECT.This study aimed at developing and validating a short, sensitive battery to assess cognitive deficits associated with ECT in India.Battery for ECT Related Cognitive Deficits (B4ECT-ReCoDe), a brief cognitive battery (20–30 min) to assess verbal, visual, working and autobiographic memory, sustained attention, psychomotor speed and subjective memory impairment, was administered to 30 in-patients receiving bilateral ECT, one day after the 1st, 3rd and 6th ECT. Data was analysed using repeated measures analysis of variance and Pearson's correlation.Significant deficits were found in verbal, visual and autobiographic memory, psychomotor speed. Subjective experience of memory loss correlated positively with verbal memory impairment.B4ECT-ReCoDe, a brief, sensitive measure of cognitive impairments associated with ECT can be used in routine clinical practice.

Battery for ECT Related Cognitive Deficits (B4ECT-ReCoDe): Development and validation

BackgroundThe use of electroconvulsive therapy (ECT) in treatment of psychiatric disorders is associated with adverse cognitive effects. There is a need to develop a short assessment tool of cognitive functions during the course of ECT. ObjectiveThis study aimed at developing and validating a short, sensitive battery to assess cognitive deficits associated with ECT in India. MethodsBattery for ECT Related Cognitive Deficits (B4ECT-ReCoDe), a brief cognitive battery (20–30min) to assess verbal, visual, working and autobiographic memory, sustained attention, psychomotor speed and subjective memory impairment, was administered to 30 in-patients receiving bilateral ECT, one day after the 1st, 3rd and 6th ECT. Data was analysed using repeated measures analysis of variance and Pearson's correlation. ResultsSignificant deficits were found in verbal, visual and autobiographic memory, psychomotor speed. Subjective experience of memory loss correlated positively with verbal memory impairment. ConclusionsB4ECT-ReCoDe, a brief, sensitive measure of cognitive impairments associated with ECT can be used in routine clinical practice.

Ictal EEG fractal dimension in ECT predicts outcome at 2 weeks in schizophrenia

Studies of electroconvulsive therapy (ECT) have found an association between ictal electroencephalographic (EEG) measures and clinical outcome in depression. Such studies are lacking in schizophrenia. Consenting schizophrenia patients receiving ECT were assessed using the Brief Psychiatric Rating Scale (BPRS) before and 2 weeks after the start of ECT. The patients' seizure was monitored using EEG. In 26 patients, completely artifact-free EEG derived from the left frontal-pole (FP1) channel and electrocardiography (ECG) were available. The fractal dimension (FD) was computed to assess 4-s EEG epochs, and the maximal value from the earliest ECT session (2nd, 3rd or 4th) was used for analysis. There was a significant inverse correlation between the maximum FD and the total score following 6th ECT. An inverse Inverse correlation was also observed between the maximum FD and the total number of ECTs administered as well as the maximum heart rate (HR) and BPRS scores following 6th ECT. In patients with schizophrenia greater intensity of seizures (higher FD) during initial sessions of ECT is associated with better response at the end of 2 weeks.

Changes in Heart Rate Variability of Depressed Patients after Electroconvulsive Therapy

Objective. As few, small studies have examined the impact of electroconvulsive therapy (ECT) upon the heart rate variability of patients with major depressive disorder (MDD), we sought to confirm whether ECT-associated improvement in depressive symptoms would be associated with increases in HRV linear and nonlinear parameters. Methods. After providing consent, depressed study participants (n = 21) completed the Beck Depression Index (BDI), and 15-minute Holter monitor recordings, prior to their 1st and 6th ECT treatments. Holter recordings were analyzed for certain HRV indices: root mean square of successive differences (RMSSD), low-frequency component (LF)/high-frequency component (HF) and short-(SD1) versus long-term (SD2) HRV ratios. Results. There were no significant differences in the HRV indices of RMSDD, LF/HF, and SD1/SD2 between the patients who responded, and those who did not, to ECT. Conclusion. In the short term, there appear to be no significant improvement in HRV in ECT-treated patients whose depressive symptoms respond versus those who do not. Future studies will reveal whether diminished depressive symptoms with ECT are reliably associated with improved sympathetic/parasympathetic balance over the long-term, and whether acute changes in sympathetic/parasympathetic balance predict improved mental- and cardiac-related outcomes.

Glutamate normalization with ECT treatment response in major depression

Though psychotherapy, medications and brain stimulation are used to treat major depressive disorder (MDD), treatment response depends on several individualized clinical factors and frequently requires multiple treatment trials. To guide more effective personalized interventions, there is thus a need to identify biological markers to elucidate the mechanisms of response to predict treatment outcomes in MDD. Prior evidence suggests neurochemical disturbances in mood regulating networks, including the anterior cingulate cortex (ACC) and connected prefrontal and subcortical centers, contribute to MDD and play a role in treatment response1–4. To identify treatment-related changes in neurochemical markers implicated in MDD2, 4, 5, we applied single-voxel Proton Magnetic Resonance Spectroscopy (1HMRS) for cross sectional and longitudinal analysis of ACC glutamate (Glu), choline (Cho) and N-acetyl aspartate (NAA) in 10 patients with DSM-IVR diagnoses of MDD (mean age: 44.0 years, 7.93 SD; 6 females) followed prospectively during Index treatment and 10 demographically similar controls (mean age: 39.03 years, 9.55 SD; 6 females). Electroconvulsive therapy (ECT) was used as the therapeutic modality since it is a highly effective procedure for treating severe MDD that elicits rapid response in eligible individuals6. Patients were assessed at three time points: baseline, and after the 2nd and 6th ECT sessions, corresponding to ~48 hrs and 2 weeks post treatment initiation (see Supplementary Information (SI) for clinical details). The Hamilton (HAMD) and Montgomery-Asberg (MADRS) Depression Rating Scales recorded therapeutic response. Controls were assessed twice, ~2-weeks apart, to determine disease effects, normative values and to estimate the variance of serial scanning. All subjects, without neurological disorders, alcohol/substance abuse or dementia, provided UCLA Institutional Review Board-approved informed consent. High-resolution T1-weighted MPRAGE structural (FOV: 256; voxel size: 1 mm3; TR/TE: 2200/5.16 ms; flip angle: 12°) and single-voxel Point Resolved Spectroscopy (PRESS) acquisitions (TR/TE: 2000/30 ms; spectral width 2000 Hz; 1024 points) with (128 averages) and without water suppression (8 averages) were collected on a Siemens 3T Allegra system. Automatic and manual 3D shimming was applied to reduce B0 inhomogeneity for voxels (20×18×12 mm3) placed in midline anterior ACC gray matter [Fig 1A; see SI]. LCModel computed the levels of Glu, Cho and NAA relative to the unsuppressed water signal. Derived metabolites levels were corrected for voxel CSF content using corresponding tissue classified T1-weighted images7. Figure 1 A) Voxel placement and 1HMRS spectra in a single subject, B) Mean CSF-adjusted glutamate (left), NAA (middle) and choline (right) levels at each time point in patients and controls indicating significant disease effects (purple), group by time interactions ... Metabolites (with variances 0.50). For baseline comparisons, including age and gender as covariates, main effects of diagnosis were observed for Glu only, F(1,19)=8.61, p<.01 (lower in patients). General Linear Mixed Models (GLMMs) including metabolites from each time point and a subject variable to control for within-subject correlations, also showed a significant diagnosis by time interaction for Glu, F(1, 21.98)=4.94, p<.037. Glu levels increased significantly over time in patients approximating normal levels, F(2, 16.56)=4.05, p<.037, but remained stable in controls (p=.47). In patients, subsequent pairwise comparisons showed significant Glu elevations between baseline and the 6th ECT, p<.018. In the absence of overall effects of time, pairwise comparisons in patients also showed significant decreases in NAA, p<.048, and increases in Cho, p<.047 between baseline and the 6th ECT [Fig 1B]. HAMD and MADRS scores improved significantly with treatment, F(2, 16.67)=29.48 and F(2, 13.12)=19.79, both p<.0001. Variations in Glu correlated with MADRS scores across time, F(1, 15.78)=4.49, p<.05. Baseline Cho levels correlated significantly with overall change in HAMD ratings, r=.85, p<.0001; baseline Glu levels also showed a trend for predicting HAMD change, r=.59, p<.08 [Fig 1C]. MDD-related reductions in ACC glutamate normalize with ECT treatment and associate with clinically determined therapeutic response. Results are in line with prior reports indicating glutamate deficits in MDD2, 4 and extend earlier observations of increased glutamate/glutamine (Glx) in the left ACC in patients treated with ECT8, shown here to also mirror clinical response. NAA and Choline, though not discriminating diagnostic groups at baseline, also showed treatment effects in patients. Together, these neurochemical changes suggest treatment-induced neuroplasticity in the structure, density and integrity of mature neurons9 and/or may reflect changes relating to adult neurogenesis in connected hippocampal and subventricular regions10. Results also support that neurochemical signatures in the ACC may predict future therapeutic response through mechanisms potentially overlapping with other forms of treatment. Studies including additional treatment modalities, larger samples, and longer follow-ups with relapse rates may confirm these observations.

Interictal Slow-Wave Focus in Left Medial Temporal Lobe during Bilateral Electroconvulsive Therapy

The interictal state between two electroconvulsive therapy (ECT) sessions is clinically characterised by possible cognitive adverse effects like mild amnestic syndrome. ECT-induced mnestic deficits can persist for several weeks after ECT. Electrophysiologically, slowing of brain electrical activity in the interictal state has often been reported. Especially, for bilateral ECT a correlation between enhanced left frontotemporal theta activity and retrograde amnesia has been demonstrated. This study focuses on the topographic distribution of cortical slow-wave oscillations during the interictal state of a bilateral ECT cycle. Twelve patients with major depression have been investigated with 32-channel resting EEG 24 h after the 6th ECT session. As controls, 8 major depressive patients were investigated prior to antidepressive treatment. The generating sources of slow-wave activity are estimated within the theta frequency band with low-resolution brain electromagnetic tomography. Source analysis revealed a distinct pattern of theta activity in the depth of the left temporal lobe (fusiform and parahippocampal gyri, Brodmann areas 37 and 36, respectively; p< 0.05) during the interictal state. This finding suggests a dysfunction of the left medial temporal lobe memory system during the interictal state of a bilateral ECT cycle. It will further be discussed whether it is possible to obtain information about activity of deep brain structures like the hippocampal formation from scalp-recorded signals.

Effect of electroconvulsive therapy without anticonvulsive premedication on serum growth hormone in man.

Serum concentrations of human growth hormone (HGH) were measured in psychiatric patients during the first, third and sixth electroconvulsive therapy (ECT) without anticonvulsive premedication. Serum HGH increased 30 min after the application of current and no differences were found between responses to 1st, 3rd, or 6th ECT. Maximal increase of serum glucose was seen after the first ECT and gradual decreases after the 3rd and 6th ECT were observed