Anesthetic Agents For Electroconvulsive Therapy Research Articles

Ketamine and Electroconvulsive Therapy: Better Together?

IntroductionMajor depressive disorder (MDD) is a highly prevalent clinical condition with a leading cause of disability worldwide. The currently available therapeutic agents have important limitations regarding side effects, partial or non-responsiveness. Patients are considered to have treatment-resistant depression (TRD) if there is no effect or minimal effectiveness after receiving adequate dose-duration use of antidepressants from two different categories. For this patients, electroconvulsive therapy (ECT) can be a treatment option and new therapies appear to tackle TRD like ketamine, a dissociative anesthetic and analgesic.ObjectivesThe authors elaborate a narrative literature review to understand if ketamine might enhance the antidepressant efficacy of ECT.MethodsPubMed database searched using the terms “Electroconvulsive therapy”, “ketamine” and “treatment-resistant depression”.ResultsECT is currently recommended as an end-line therapy for TRD. Memory impairment after ECT could be a consequence of indiscriminate activation or saturation of glutamate receptors during the treatment, disrupting hippocampal plasticity involved in memory. Ketamine inhibits N-methyl-d-aspartate (NMDA) receptors, while stimulating glutamate release and was proposed as an ECT adjuvant, might reduce cognitive adverse effects, time until response/ remission and inclusively improve response rates to ECT. However, response and remission rates of ketamine in ECT showed no significant difference from the comparator groups and was associated with higher rates of psychiatric and cardiovascular adverse events.ConclusionsThe results did not support the use the combination of ketamine and propofol as anesthetic agents for ECT in patients with MDD. However, further studies are needed to investigate the beneficial clinical and cognitive effects of ketamine alone in ECT settings.DisclosureNo significant relationships.

Ketamine for Adults With Treatment-Resistant Depression or Post-Traumatic Stress Disorder


 Two randomized controlled trials reported mixed evidence on the efficacy of repeated IV ketamine infusions for improving post-traumatic stress disorder. One randomized controlled trial with small sample size found that repeated IV ketamine infusions significantly improved post-traumatic stress disorder symptoms compared with midazolam in civilian population, while the other randomized controlled trial with larger sample size could not demonstrate a significant efficacy on post-traumatic stress disorder symptoms compared with placebo in military population. The antidepressant effects of ketamine were rapid, but the effects were not sustained after few weeks of post-treatment follow-up.
 One randomized controlled trial comparing IV ketamine with IV esketamine found both treatments had comparable acute antidepressant effects for treatment-resistant depression 24 hours following infusion.
 Two randomized controlled trials provided mixed evidence on the efficacy of single infusion of IV ketamine that was used as anesthetic agent for electroconvulsive therapy for treatment-resistant depression. One randomized controlled trial involving military population showed that patients undergoing electroconvulsive therapy for treatment-resistant depression with ketamine anesthesia had similar improvement of depression when compared with patients undergoing electroconvulsive therapy with methohexital anesthesia. However, in other randomized controlled trial comparing with propofol-based anesthesia in a civilian population, ketamine-based anesthesia provided faster improvement in depressive symptoms and fewer electroconvulsive therapy treatments to achieve disease remission.
 In a small randomized controlled trial, alternate infusions of subanesthetic dose of ketamine or midazolam with alternate electroconvulsive therapy showed no significant difference in antidepressant effects between groups.
 The efficacy of oral ketamine was demonstrated in 1 randomized controlled trial that repeated administration of oral ketamine significantly reduced depressive symptoms compared with placebo.
 A small retrospective chart review study showed that repeated administration of intramuscular ketamine had no significant differences in the improvement of depressive and anxiety symptoms compared with repeated transcranial magnetic stimulation.
 Findings suggest overall safety and tolerability of ketamine for treatment of post-traumatic stress disorder or treatment-resistant depression. Most frequent side effects associated with ketamine were dissociative symptoms and cardiovascular changes such as increased blood pressure and heart rate, but these effects were transient.
 The Danish guideline recommend against the use of IV ketamine in patients with treatment-resistant depression, due to low quality and insufficient evidence regarding the lack of long-term efficacy and the risk of abuse of ketamine. Likewise, the Canadian guideline recommends IV ketamine be considered as third-line treatment for adults with TRD, because of the short-lived efficacy of ketamine, its side effects, and the lack of strategies for relapse prevention after ketamine infusions.

The Combination of Propofol and Ketamine Does Not Enhance Clinical Responses to Electroconvulsive Therapy in Major Depression-The Results From the KEOpS Study.

ObjectiveWe investigated the clinical effects of the combination of ketamine and propofol as anesthetic agents during electroconvulsive therapy (ECT) in patients with uni- or bipolar major depressive episodes. We hypothesized that ketamine may confer short- and long- term advantages in improving depressive symptoms at the early stages of ECT.MethodsIn a randomized placebo-controlled trial, remission rates after 4 and 8 weeks of ECT were compared between patients who were randomly allocated to receive either the combination of ketamine (0.5 mg/kg) + propofol (n= 11) or placebo + propofol (n = 16). Depressive symptoms were assessed weekly using the Montgomery–Åsberg Depression Rating Scale (MADRS); ECT sessions were administered twice per week for a maximum of 8 weeks (16 sessions).ResultsAfter 4 weeks, we observed significantly fewer remitters (MADRS score < 10) in the ketamine + propofol group (0/11; 0%) than in the placebo + propofol group (5/16; 31%; χ2 = 4.22; p = 0.040). No significant difference was observed between the two groups regarding the number of patients who achieved remission weekly throughout the study period (Chi² = 3.588; p = 0.058). The mean duration of seizures was significantly shorter in the ketamine + propofol group than in the placebo + propofol group.ConclusionsThe results from the current study corroborated results from previously published studies and did not support the use of the combination of ketamine + propofol as an anesthetic agent for ECT in patients with major depressive episodes in clinical settings.

Esketamine nasal spray combined with an oral antidepressant for relapse prevention in treatment-resistant depression: results of a double-blind, randomized withdrawal, multicenter study (sustain-1)

To assess the clinical utility of ketamine as an anesthetic agent for electroconvulsive therapy (ECT), based upon recent findings that ketamine may have antidepressant properties. Depressed ECT patients were randomly assigned to receive anesthesia with either ketamine or methohexital. Outcome measures included assessments of depressive severity, cognition, post-anesthesia side effects, and hemodynamics. Twenty one patients were treated with ketamine and 17 with methohexital. There were no significant differences in depression or cognitive outcomes between the two drugs. Additionally, there were no measures of post-anesthesia tolerability or hemodynamics which favored ketamine. Ketamine anesthesia does not accelerate the antidepressant effect of ECT or diminish the cognitive side effects, at least as measured in this study. Furthermore, there is no apparent benefit of ketamine for speed or quality of post-ECT recovery, and it is associated with higher systolic blood pressures after the treatments. Ketamine is associated with longer motor seizure duration than methohexital.

Comparison of Propofol and Thiopentone as anaesthetic agents for electroconvulsive therapy - A prospective, double blinded cross over trial

Comparison of Propofol and Thiopentone as anaesthetic agents for electroconvulsive therapy - A prospective, double blinded cross over trial

Comparison of Propofol and Thiopentone as anaesthetic agents for electroconvulsive therapy - A prospective, double blinded cross over trial

Comparison of Propofol and Thiopentone as anaesthetic agents for electroconvulsive therapy - A prospective, double blinded cross over trial

Comparison of thiopentone sodium and propofol as anesthetic agents for modified electroconvulsive therapy

Electroconvulsive therapy is a simple procedure, performed on highly diverse patient population with severe, drug resistant depression and other psychiatric disorders. Due to the occurrence of physical and psychological trauma caused to the conscious patient, has led to the concept of modified electroconvulsuve therapy. Ideal anaesthetic used for electroconvulsive therapy should have characteristics that include rapid induction, shorter duration of action, minimal side effects, rapid recovery and no interference with electroconvulsive therapy efficiency. The present study has compared propofol, which has been increasingly used recently with thiopentone, the drug most widely acceptable even today as anaesthetic agents for electroconvulsive therapy. This study was performed to assess the comparative effects of propofol and thiopentone sodium on recovery profile, hemodynamic stability and seizure duration during and after electroconvulsive therapy.

Influence of valproate on the required dose of propofol for anesthesia during electroconvulsive therapy of bipolar affective disorder patients

BackgroundPropofol is often used as an anesthetic agent for electroconvulsive therapy (ECT). In recent studies, propofol was shown to possess significant seizure-shortening properties during ECT. “Valproate” is a mood stabilizer used mainly in the treatment of bipolar affective disorder. It is reported that valproate, being an anticonvulsant, raises the seizure threshold, thus decreases the efficacy of ECT treatment.AimThe purpose of our study was to compare the dose of propofol in valproate-using patients and valproate-free patients.MethodsIn an open design, 17 patients with bipolar affective disorder manic episodes who were to be treated with valproate and ECT in combination, were compared with 16 manic-episode patients who were to be treated with ECT but not valproate. The two groups were compared on the basis of electroencephalography-registered seizure duration and the propofol dosage required to induce anesthesia.ResultsValproate, compared with no valproate treatment, results in a decrease in the propofol dose required to induce anesthesia. In the valproate group of study participants, seizure duration was significantly shorter than in the valproate-free group.ConclusionThe results suggest that valproate reduces the dose of propofol required for anesthesia during ECT treatment in patients with bipolar affective disorder manic episodes. Although propofol is a safe and efficacious anesthetic for ECT treatment, lower doses of propofol should be used to induce anesthesia for patients under valproate treatment. When the clinician needs to prolong seizure duration in patients treated with valproate, interruption of the valproate treatment or an anesthetic agent other than propofol should be considered.

A randomized comparison of ketamine versus methohexital anesthesia in electroconvulsive therapy

To assess the clinical utility of ketamine as an anesthetic agent for electroconvulsive therapy (ECT), based upon recent findings that ketamine may have antidepressant properties. Depressed ECT patients were randomly assigned to receive anesthesia with either ketamine or methohexital. Outcome measures included assessments of depressive severity, cognition, post-anesthesia side effects, and hemodynamics. Twenty one patients were treated with ketamine and 17 with methohexital. There were no significant differences in depression or cognitive outcomes between the two drugs. Additionally, there were no measures of post-anesthesia tolerability or hemodynamics which favored ketamine. Ketamine anesthesia does not accelerate the antidepressant effect of ECT or diminish the cognitive side effects, at least as measured in this study. Furthermore, there is no apparent benefit of ketamine for speed or quality of post-ECT recovery, and it is associated with higher systolic blood pressures after the treatments. Ketamine is associated with longer motor seizure duration than methohexital.

Effect of Propofol Versus Sodium Thiopental on Electroconvulsive Therapy in Major Depressive Disorder

To compare propofol and sodium thiopental as anesthetic agents for electroconvulsive therapy (ECT) in major depression with respect to clinical effect. Participants were composed of 96 patients with depression who were administered either propofol or sodium thiopental as an anesthetic agent for bilateral ECT. The Hamilton Depression Rating Scale was administered at baseline and after 6 treatments. Algorithm-based charge dosing was used. There was a statistically significant difference between the groups regarding postintervention Hamilton Depression Rating Scale score. The preintervention mean (SD) scores in the propofol group and the sodium thiopental group were 37.3 (2.2) and 36.7 (1.2), respectively. The postintervention mean (SD) scores in the propofol group and the sodium thiopental group were 10.7 (1.8) and 13.4 (3.3), respectively. No correlation was found between clinical response and age, weight, and body mass index. There was no association between the groups' seizure time and duration of recovery. In conclusion, propofol may improve major depressive disorder more than sodium thiopental in patients who are receiving ECT.

Comparison of methohexital and etomidate as anesthetic agents for electroconvulsive therapy in affective and psychotic disorders

BackgroundECT is a well-established treatment for severe depression. The available data on psychosis are limited, but reliable. Its therapeutic potential relies on the induction of a generalized seizure. Besides other narcotics, methohexital and etomidate are used for general anesthesia in ECT. Since prolonged seizures have been reported following the use of etomidate, it can be deduced that the substances might differ in their anticonvulsant properties, resulting in a lower increase in stimulus intensity during the course of treatment under etomidate. Besides this hypothesis, we aimed to investigate the differential effects of etomidate and methohexital on clinical features, ECT parameters and side effects of the treatment. MethodsWe performed a retrospective analysis of treatment data of patients with affective and psychotic diagnosis who received general anesthesia for ECT either with etomidate or with methohexital. ResultsECT with etomidate and methohexital was equally effective. During the course of therapies the administered electric charge increased significantly and equally in both treatment groups. In the methohexital group, but not in the etomidate group, electroencephalographic seizure duration had a declining trend during the course of therapies. We observed more side effects during and immediately after ECT in the methohexital group than in the etomidate group. LimitationsThe limitations of this study are that the patients received various psychotropic co-medications, which influence ictal parameters differently, and, secondly, the study is based on a retrospective analysis. ConclusionThe results of our analysis suggest that etomidate and methohexital affect ictal parameters to different extents. Longer seizure duration and fewer side effects are in favor of etomidate.

A Within-Subject Comparison of Propofol and Methohexital Anesthesia for Electroconvulsive Therapy

The optimal anesthetic for electroconvulsive therapy (ECT) is a frequently studied but unresolved issue. Methohexital and propofol are 2 widely used anesthetic agents for ECT. The purpose of this study was to determine which of the 2 agents was associated with superior clinical outcomes. Records from all patients who had undergone separate ECT courses with methohexital and propofol between 1992 and 2008 (n = 48) were reviewed for a retrospective within-subject comparison of outcome measures. The clinical outcomes we examined were number of treatments required in a course of ECT, changes in the Montgomery-Åsberg Depression Rating Scale and Mini Mental Status Examination, and length of stay in the hospital after initiation of ECT. Additionally, we compared treatment delivery between methohexital and propofol treatment courses, measuring rate of restimulation for brief seizures, seizure duration, percentage of treatments that were bilateral, and average charge administered. Data from 1314 treatments over 155 ECT courses were reviewed. Improvement in depressive symptoms, based on the Montgomery-Åsberg Depression Rating Scale, was not affected by choice of anesthetic agent. However, when right unilateral electrode placement was used, patients receiving propofol required significantly more treatments than those receiving methohexital. Propofol was also associated with a significantly higher requirement for bilateral ECT and higher stimulus dosing. Seizure duration was significantly shorter in the propofol condition, with more patients requiring restimulation for brief seizures. Length of stay in the hospital and cognitive outcomes were not significantly different between propofol and methohexital treatments. We recommend methohexital as the induction agent of choice for ECT, especially with right unilateral placement.

A comparison of propofol and thiopentone for electroconvulsive therapy

Objectives:To compare propofol and thiopental as anesthetic agents for electroconvulsive therapy (ECT) with respect to seizure duration, stimulus charge, and clinical effects.Materials and Methods:Randomized, blinded study of 28 patients of depression treated with bilateral ECT. In group P (n = 14), sedation was achieved with propofol 1.5 mg/kg, whereas in group T (n = 14), it was achieved with thiopentone 3 mg/ kg IV. Succinylcholine 0.4 mg/kg intravenous was given in all patients as for neuromuscular blockade.Results:The mean seizure duration of the patients in the thiopental group was 83 ± 34.43 seconds vs. 94.45 ± 21.37 seconds in the propofol group (P < 0.01). The energy delivered per treatment was 10.88 ± 4.78 J in the thiopental group vs. 12.20 ± 4.53 J in the propofol group (P < 0.05). Number of ECTs required were significantly higher in propofol group (9.71 ± 2.87) as compared to thiopental group (5.86 ± 0.36) P < 0.0001. No significant difference in duration of hospitalization was seen in both groups. The mean score on Mini-Mental State Examination (MMSE) was 29.14 in the thiopental group vs. 29.57 in the propofol group (P > 0.05). The mean score on Beck Depression Inventory (BDI) was 7.14 in the thiopental group vs. 3.29 in the propofol group (P < 0.05).Conclusions:Propofol significantly increases number of ECT required to treat although the patients received higher electrical charge and had longer seizure duration. BDI scores suggest this resulted in better outcome. Results, however, might be confounded by the differences in pharmacological treatment in the groups.

Comparison of Propofol and Thiopental as Anesthetic Agents for Electroconvulsive Therapy

To compare propofol and thiopental as anesthetic agents for electroconvulsive therapy (ECT) with respect to seizure duration, stimulus charge, clinical effect, and cognitive side effects. Randomized, blinded study of 62 depressed patients treated with bilateral ECT. Algorithm-based charge dosing was used. The mean seizure duration of the patients in the thiopental group was 36.3 seconds versus 25.7 seconds in the propofol group (P = 0.001). The charge per treatment was 79.5 mC in the thiopental group versus 109.8 mC in the propofol group (P = 0.026). Sixteen patients in the propofol group (52%) reached the highest electrical dose versus 8 patients (26%) in the thiopental group (P = 0.014). No difference in response to treatment or number of treatments was observed. The mean score on Mini-Mental State Examination (MMSE) was 28.9 in the thiopental group versus 26.8 in the propofol group (P = 0.014). However, age distribution of patients completing the study differed between the groups. Propofol significantly decreases seizure duration without significant difference in the clinical outcome. Using the employed treatment algorithm, patients anesthetised with propofol received higher electrical charge. Mini-Mental State Examination scores suggest that this results in more severe cognitive side effects. Results, however, might be confounded by the differences in age distribution in the groups.

Effects of the Addition of Remifentanil to Propofol Anesthesia on Seizure Length and Postictal Suppression Index in Electroconvulsive Therapy

Propofol is a widely used anesthetic agent for electroconvulsive therapy (ECT). However, there are concerns that its anticonvulsant effect may interfere with the efficacy of ECT. We aimed to investigate the effects on seizure activity of the addition of the opiate remifentanil to propofol anesthesia for ECT. A retrospective analysis of 633 treatments in 73 patients was conducted. At each treatment, patients had received anesthesia with propofol alone or propofol plus remifentanil, depending on which anesthetist was providing anesthesia. Analysis of variance was performed to examine the effects of the anesthetic used, the electrode placement, the dose of electricity administered, and the stage in the course of treatment. Dependent variables were electroencephalogram seizure length and postictal suppression index (PSI). Addition of remifentanil resulted in a small but significantly lower dose of propofol being used to induce unconsciousness. Addition of remifentanil affected seizure length, mainly related to an effect when placement was right unilateral (F = 5.70; P = 0.017). There was also a significantly increased PSI (F = 4.3; P = 0.039), which was not dependent on dose or on placement. The data suggest that addition of remifentanil to propofol anesthesia significantly alters seizure indices. This may be secondary to a reduction in the amount of propofol required or to an independent effect of remifentanil. The increase in PSI in particular suggests that addition of remifentanil may improve clinical response. However, this can only be examined in a randomized controlled trial.

Propofol and Methohexital as Anesthetic Agents for Electroconvulsive Therapy

Propofol is often used as an anesthetic agent for electroconvulsive therapy (ECT). Whether the relatively short seizure duration, resulting from the medication, deteriorates the seizure quality and therapeutic outcomes, or whether propofol might be associated with small but significant post-ECT cognitive impairments, is still a subject of controversy. The purpose of our study was to test these hypotheses in comparison with methohexital. In a double-blind, controlled study, 50 patients with severe major depression who were to be treated with ECT were randomly assigned to anesthesia with propofol (120.9 +/- 50.0 mg) or methohexital (83 +/- 26.3 mg) and were observed for 2 months. The 2 drugs were compared on the basis of electroencephalography-registered seizure duration, mean blood pressure, as well as pulse frequency, seizure efficacy index, and postictal suppression. Systolic and diastolic blood pressure, and seizure duration and quality were recorded consecutively during ECT treatments. Changes in depressive symptoms and cognitive functions were measured at 5 time points, pre-ECT, after the third to fifth ECT, post-ECT treatment, and at a follow-up examination 2 and 8 weeks after the last ECT treatment. Patients on propofol showed a significantly lower increase in blood pressure post-ECT (P < 0.001), their seizure duration was comparable to patients on methohexital (P = 0.072), and seizure quality was significantly superior, as was measured by the Postictal Suppression Index (P = 0.020), and comparable to the methohexital group as measured by the Seizure Efficacy Index (P = 0.160). The improvement of depressive symptoms and the improvement in cognitive functions were similar in both groups (with the exception of the results from 2 cognition tests). Propofol, as compared with methohexital, results in a more moderate increase in blood pressure and shorter seizure duration. The seizure quality did not differ significantly between the 2 groups. We detected a tendency toward improved cognitive performance after anesthesia with propofol as compared with methohexital, but with statistical significance in only 2 cognition trials. Therefore, propofol is a safe and efficacious anesthetic for ECT treatment.

A Comparison of Propofol and Thiopentone Use in Electroconvulsive Therapy

The purpose of this study was to compare thiopentone and propofol administration for electroconvulsive therapy (ECT) in terms of associated efficacy and cognitive side effects in the immediate and medium term. Participants comprised 30 depressed patients who were administered either propofol or thiopentone as an anesthetic agent for ECT. Clinical rating scales and a battery of neuropsychological tests were administered at baseline, after 6 treatments, 1 to 3 days after treatment end point, and at 1-month follow-up. Thiopentone administration was associated with advantages in efficacy and cognitive side effects compared with propofol administration. This study reports some serendipitous findings regarding the comparative effects of the anesthetic agents, propofol and thiopentone. Although limited by small sample size, results suggest that thiopentone has advantages for use as an anesthetic agent with ECT compared with propofol. It also highlights the need for further investigation of the impact of anesthetic agents on the cognitive side effects and efficacy of ECT.

A Retrospective Comparison of Anesthetic Agents in Electroconvulsive Therapy

A recent lack of availability of the anesthetic agent methohexital in the United States allowed for a naturalistic study of the efficacy and the adverse effects of alternatives. Methohexital, propofol, and thiopental were compared as anesthetic agents for electroconvulsive therapy in 95 patients treated during a 23-month period in a general public hospital. Missed seizures and arrhythmias were infrequently observed (<4% for any agent). Methohexital was found significantly related to longer seizure durations in comparison with both other agents (P < 0.01). The use of propofol was associated with increased risk of missed seizure (8.9%) compared with methohexital (3.9%) and thiopental (3.2%). Propofol was also associated with higher doses of administered energy, with a statistically significant difference (P = 0.018) observed between propofol and thiopental. Although propofol required the greatest energy delivery, it was associated with the shortest seizure durations. Methohexital resulted in the longest seizure duration, and thiopental was associated with the least amount of energy delivery with an intermediate seizure length.

Propofol and methohexital as anaesthetic agents for electroconvulsive therapy (ect): A comparison of seizure-quality measures, vital signs and therapeutic efficacy

Pre-menstrual dysphoric disorder (PMDD), a dysphoric form of pre-menstrual syndrome, is included as a diagnosis for further study in the DSM-IV-TR (APA, 2000). The present study investigated whether a marker of risk for major depressive disorder (MDD), prefrontal brain asymmetry, also characterizes women with PMDD.In a sample of 25 college women with PMDD symptomatology and 25 matched controls, resting frontal electroencephalographic (EEG) activity was assessed on four occasions within a two-week span.Across several frontal sites women with PMDD had relatively less left than right prefrontal brain activity, consistent with a diathesis-stress model for menstrual-related dysphoria.The findings suggest an overlap in the risk profile for MDD and PMDD.

Propofol and Methohexital as Anesthetic Agents for Electroconvulsive Therapy (ECT)

In a randomized crossover study, the influence of the anesthetics methohexital and propofol on EEG seizure parameters, seizure-quality measures, vital signs, and oxygen saturation (SpO2) and end-tidal carbon dioxide tension (ETCO2) was investigated; 146 treatments of 31 patients were analyzed. Significant differences were observed between agents for mean postictal pulse and blood pressure values. With methohexital, there was a clear postictal increase of mean blood pressure from 126/78 mm Hg to 161/102 mm Hg, whereas there was no increase with propofol (p = 0.00), and with methohexital, a postictal increase of the mean pulse rate from 81 to 90 beats/min and a slight decrease with propofol (79 to 78 beats/min). There were no differences in the SpO2 and ETCO2. The mean seizure duration for unilateral treatments was significantly longer with methohexital (52.7 s) compared with propofol (34.1 s; p = 0.000), but there was no difference for the seizure-quality measures: postictal suppression index (propofol 79.7%, methohexital 77.4%) and mean integrated amplitude (30.2/31.8) were the same for both anesthetic agents. The results show that differences in seizure duration are unrelated to seizure-quality measures.