Bitemporal Electroconvulsive Therapy Research Articles

Efficacy and safety assessment of different electrode placements during electroconvulsive therapy for the treatment of depression: a comparison of bitemporal, bifrontal and unilateral right-sided stimulation - a narrative review

Introduction: Consequences of depressive syndrome are changes in central nervous system, especially the reduction in volume and disturbances in neuronal metabolism. There are disturbances in cerebral blood flow, in areas responsible for concentration, memory and regulation of behaviour and emotions. ECT method has shown considerable effectiveness in treatment of depression. It has invariably remained effective as a form of treatment in psychiatry for many years. The way in which the method itself is applied and location of stimulation electrodes remains controversial. In clinical practice, bitemporal, bilateral or right unilateral applications are used, each of which activates slightly different regions in brain, resulting in different therapeutic effects. Methods: A review of available literature was performed by searching PubMed and Google Scholar databases, using the following keywords: bifrontal ECT, bitemporal ECT, right unilateral ECT, cognitive function for original papers, meta-analyses and review papers in Polish and English published from 1990 to 2022. The SANRA scale was used to maintain the high quality of the narrative review. Results: All three methods are effective in treating depressive disorders, but differ in impact on cognitive function. Bi-frontal stimulation is the most effective in emergencies, however related to a higher risk of cognitive impairment. Milder cognitive impairment, with similar therapeutic efficacy, is observed with bitemporal and unilateral placement. Conclusions: Individualised selection of ECT method is recommended, depending on patients' needs and clinical condition. The importance of individualising the dose, location of electrodes, and monitoring of cognitive function is emphasised in order to increase the effectiveness and minimise side effects. Keywords: bifrontal ECT, bitemporal ECT, right unilateral ECT, cognitive function

Electroconvulsive therapy disrupts functional connectivity between hippocampus and posterior default mode network

BackgroundThe mechanisms underlying memory deficits after electroconvulsive therapy (ECT) remain unclear but altered functional interactions between hippocampus and neocortex may play a role. ObjectivesTo test whether ECT reduces functional connectivity between hippocampus and posterior regions of the default mode network (DMN) and to examine whether altered hippocampal-neocortical functional connectivity correlates with memory impairment. A secondary aim was to explore if these connectivity changes are present 6 months after ECT. MethodsIn-patients with severe depression (n = 35) received bitemporal ECT. Functional connectivity of the hippocampus was probed with resting-state fMRI before the first ECT-session, after the end of ECT, and at a six-month follow-up. Memory was assessed with the Verbal Learning Test – Delayed Recall. Seed-based connectivity analyses established connectivity of four hippocampal seeds, covering the anterior and posterior parts of the right and left hippocampus. ResultsCompared to baseline, three of four hippocampal seeds became less connected to the core nodes of the posterior DMN in the week after ECT with Cohen's d ranging from −0.9 to −1.1. At the group level, patients showed post-ECT memory impairment, but individual changes in delayed recall were not correlated with the reduction in hippocampus-DMN connectivity. At six-month follow-up, no significant hippocampus-DMN reductions in connectivity were evident relative to pre-ECT, and memory scores had returned to baseline. ConclusionECT leads to a temporary disruption of functional hippocampus-DMN connectivity in patients with severe depression, but the change in connectivity strength is not related to the individual memory impairment.

Examining the clinical effectiveness of continuation and maintenance electroconvulsive therapy in schizophrenia

ObjectiveThere are few studies that examine the effectiveness of Continuation/Maintenance Electroconvulsive Therapy (C/M-ECT) in schizophrenia, despite the documented effectiveness of acute ECT treatment. We aimed to investigate the clinical effectiveness of C/M-ECT for in-patients with Schizophrenia in a naturalistic setting. We examined the medical records of 46 in-patients who were diagnosed with Schizophrenia and had received C/M-ECT belonging to non-acute extended care service in a public psychiatry hospital in Sydney, Australia. The focus of analysis was on 138 treatment cycles (71 acute only cycles and 67 acute-continuation/maintenance cycles) across 45 subjects. A linear mixed effects model was used to describe the change in clinical global impression-severity (CGI-S) over time 4 time points viz., pre-post acute and pre-post continuation/maintenance ECT. ResultsAcute-only cycles and acute-continuation/maintenance cycles had identical pre- (M = 5, C.I. = 4–6), post-cycle CGI-S scores, and identical CGI-S difference scores (M = 0, C.I. = −1 – 1). Broadly in each continuation/maintenance cycle, we observed an initial sharp decrease in CGI-S scores followed by a logarithmic increase in scores over time, with satisfactory CGI-S score maintenance observed for approximately 6 months. Bitemporal ECT influenced CGI-S across maintenance ECT (p < 0.05) indicating smaller declines in CGI-S scores over time. ConclusionIn schizophrenia, C/M ECT preserves effects on illness severity for at least upto 6 months following an acute course of ECT. Bitemporal ECT vis a vis other electrode positions differentiated clinical severity over time.

Prescribing electroconvulsive therapy for depression: Not as simple as it used to be.

In the last century, prescribing electroconvulsive therapy usually involved considering the relative merits of unilateral versus bilateral electroconvulsive therapy, with most other parameters fixed. However, research over the last 30 years has discovered that several parameters of the electroconvulsive therapy stimulus can have a significant impact on efficacy and cognitive side effects. The stimulus dose relative to seizure threshold was shown to significantly affect efficacy, especially for right unilateral electroconvulsive therapy, where suprathreshold doses in the vicinity of 5-6 times seizure threshold were far more efficacious than doses closer to threshold. However, this did not hold for bitemporal electroconvulsive therapy, where near-threshold stimuli were equally effective as suprathreshold stimuli. Then, changes in stimulus pulse width were found to also have a significant impact on both efficacy and side effects, with ultrabrief pulse widths of 0.3 ms having significantly fewer cognitive side effects in unilateral electroconvulsive therapy than standard brief pulse widths of 1.0 ms, with only slightly reduced efficacy. Therefore, choosing the optimum electroconvulsive therapy prescription for an individual patient now requires consideration of placement, pulse width and stimulus dose relative to seizure threshold, and how these three interact with each other. This viewpoint aims to raise awareness of these issues for psychiatrists involved in electroconvulsive therapy practice.

Dynamic impedance is correlated with static impedance and seizure quality parameters in bifrontal electroconvulsive therapy.

To evoke a therapeutically effective seizure, electrical stimulation in electroconvulsive therapy (ECT) has to overcome the combined resistivity of scalp, skull and other tissues. Static impedances are measured prior to stimulation using high-frequency electrical alternating pulses, dynamic impedances during passage of the stimulation current. Static impedance can partially be influenced by skin preparation techniques. Earlier studies showed a correlation between dynamic and static impedance in bitemporal and right unilateral ECT. This study aims at assessing the correlation of dynamic and static impedance with patient characteristics and seizure quality criteria in bifrontal ECT. We performed a cross-sectional single-centre retrospective analysis of ECT treatments at the Psychiatric University Hospital Zurich between May 2012 and March 2020 and used linear mixed-effects regression models in 78 patients with a total of 1757 ECT sessions. Dynamic and static impedance were strongly correlated. Dynamic impedance was significantly correlated with age and higher in women. Energy set and factors positively (caffeine) and negatively (propofol) affecting seizure at the neuronal level were not associated with dynamic impedance. For secondary outcomes, dynamic impedance was significantly related to Maximum Sustained Power and Average Seizure Energy Index. Other seizure quality criteria showed no significant correlation with dynamic impedance. Aiming for low static impedance might reduce dynamic impedance, which is correlated with positive seizure quality parameters. Therefore, good skin preparation to achieve low static impedance is recommended.

Clinical Practice Guidelines for the Therapeutic Use of Repetitive Transcranial Magnetic Stimulation in Neuropsychiatric Disorders.

Clinical Practice Guidelines for the Therapeutic Use of Repetitive Transcranial Magnetic Stimulation in Neuropsychiatric Disorders.

Electroconvulsive Therapy Practice in Thailand: A Nationwide Survey.

To determine the characteristics of electroconvulsive therapy (ECT) practice in Thailand. A cross-sectional survey of ECT practice in Thailand was conducted. A questionnaire was sent to all 34 hospitals providing ECT services nationwide. ECT staff of each hospital were asked to complete the questionnaire. All 34 hospitals responded to the survey. The most common diagnosis was schizophrenia (5,958 patients/year), followed by bipolar disorder (982 patients/year) and major depressive disorder (869 patients/year). Brief pulse device was used in all hospitals. Bitemporal ECT was the most common type of electrode placement (88.2%), followed by bifrontal (44.1%) and right unilateral (38.2%) placement. The initial dose was determined by titration method in 24 hospitals (70.6%) and by age-based method in the remainder (29.4%). Modified ECT was always used in 25 hospitals (73.5%), including all university hospitals, 6 psychiatric hospitals (17.6%) and 10 general hospitals (29.4%). The primary anesthetics used were thiopentone (60.7%) and propofol (39.3%). Regarding acute ECT, ECT was performed three times per week in most hospitals (91.2%). The number of acute ECT treatment sessions in most hospitals was in the range of 4-6. In total, 22 hospitals (64.7%) performed continuation/maintenance ECT. Headache was the most common adverse event, followed by cognitive side effects and myalgia. ECT practice in Thailand has developed over the past two decades in many aspects. The most notable change is that the majority of patients are now treated with modified ECT. In addition, pre-treatment investigations, use of a device providing a brief pulse, unilateral electrode placement, and the monitoring of parameters during treatment are now used more widely in practice to maximize treatment efficacy while minimizing side effects. However, certain aspects of ECT can still be improved; promoting ECT education among psychiatrists and psychiatry residents could improve the quality of practice, for example.

Electroconvulsive Therapy for Neuropsychiatric Symptoms due to Major Neurocognitive Disorder: A Prospective, Observational Study.

Neuropsychiatric symptoms (NPSs) in those with major neurocognitive disorder (MNCD) include the responsive behaviors of agitation and aggression. Electroconvulsive therapy (ECT) has shown some effectiveness based on retrospective studies and one open label prospective study. We hypothesized that ECT will reduce NPSs between baseline and after treatment in those with medication-refractory behaviors. This Canadian prospective multicenter study included MNCD patients admitted to geriatric psychiatry units for the management of refractory NPSs. All treatment-refractory participants suffered from advanced MNCD. We conducted the Neuropsychiatric Inventory-Clinician version and the Pittsburgh Agitation Scale at baseline, and during and after the ECT course. A bitemporal or bifrontal ECT series based on dose titration to 1.5 to 2.5 times seizure threshold was administered. Data were collected for 33 patients with a mean age of 73 and categorized with severe MNCD using the Functional Assessment Staging of Alzheimer's Disease scale (stages 6 and 7). The data showed a drop in mean Neuropsychiatric Inventory-Clinician version from 58.36 to 24.58 (P < 0.0001). Mean Neuropsychiatric Inventory agitation subscale dropped from 7.12 to 3.09 (P = 0.007). Mean Neuropsychiatric Inventory aggression subscale dropped from 6.94 to 0.97 (P < 0.0001). There was a concomitant significant decline in Pittsburgh Agitation Scale scores. No participants dropped out because of intolerance of ECT. One participant died from pneumonia, which did not appear related to ECT. In this naturalistic study, ECT was found to be a safe and effective treatment for certain NPSs in people with MNCD. This can translate into improving quality of life.

A Retrospective Study of Postictal Suppression during Electroconvulsive Therapy

Background: electroconvulsive therapy (ECT) is the most effective treatment in treatment-resistant depression (TRD), but its response remains partial. Identifying useful indicators to guide decision making for treatment and improve clinical response remains a major issue. The objective of the present retrospective study was to determine if clinical response—early (after 5 ECT sessions) or longer-term (after 12 ECT sessions)—was associated with postictal suppression during the first ECT course and/or with postictal suppression frequency during the whole ECT course. Methods: in a retrospective study, the data of 42 patients suffering from treatment-resistant depression and receiving at least 5 ECT sessions were collected. Two sessions per week of bitemporal brief-pulse ECT sessions were administered to patients. Each of the electroencephalography (EEG) recordings were assessed to determine the presence of postictal suppression. Results: the postictal suppression from the first ECT session predicted a better long-term clinical response (after 12 ECT sessions), but not early clinical response (after only 5 ECT sessions). The postictal suppression frequency was associated with neither the short- nor the long-term clinical response. In addition, postictal suppression and short-term cognitive performances were not associated. Conclusions: this EEG indicator is clinically useful if it appears in the first ECT sessions, but it is no longer relevant in the following sessions.

A Systematic Review on Cognitive Effects of Electroconvulsive Therapy in Asian Patients.

ObjectiveElectroconvulsive therapy (ECT) is the most efficacious treatment for many major mental illnesses but is limited by cognitive side effects. However, research on the pattern and severity of ECT-related cognitive side effects is inconsistent. Furthermore, little is known about the cognitive effects of ECT in Asian populations. A systematic review was conducted to examine objective cognitive performance following ECT in the Asian context.MethodsThis review systematically identified studies assessing ECT-related cognitive effects in PubMED, PsychINFO, The Cochrane Library, Journal of ECT and major databases in Asian countries. The search included publications from peer-reviewed journals of languages other than English.ResultsA total of 6,322 studies were identified; 823 were assessed for eligibility, of which 16 studies met the search criteria and were included in this review. Majority used high dose Bitemporal ECT for Depression and/or Schizophrenia. Cognitive impairment, which could occur immediate to the first ECT session, was reported in only 9 out of the 16 studies. However, deficits were observed to resolve as early as 3 weeks after the initiation of ECT. The remaining studies reported no impairment or even improvement after ECT.ConclusionThere is no consistent evidence that suggests ECT causes cognitive deficits in patients, despite the widespread use of high dose Bitemporal ECT. This review suggests that Asian patients, presenting with a different psychiatric profile, may respond to high-dose Bitemporal ECT differently from Western samples.

Abstract- Poster

INTRODUCTIONInternet Gaming Disorder (IGD) is a condition characterised by maladaptive use of internet for playing video games having negative consequences on individual’s functioning. DSM-5 includes IGD under conditions proposed for further study while ICD-11 proposes a diagnosis of Gaming Disorder (GD). Prevalence varies from 0.2% to 34%. The literature about treatment of IGD is limited to few studies of bupropion, escitalopram & naltrexone (only case report). We present a case of IGD treated with naltrexone along with CBT.CASE DETAILSA 15-year-old male, presented with complaints of increased time spent on playing computer games, decline in academics and personal care, irritability when not allowed to play games and difficulty in stopping playing games once initiated since last 1 ½ years. Diagnosis of IGD was considered. Internet Gaming Disorder Scale – Short Form (IGDS9-SF) score was 37. Naltrexone was initiated along with CBT. Adolescent showed improvement and IGDS9-SF score decreased to 20 over a period of 3 months. Adolescent is maintaining improvement on follow up.CONCLUSIONCurrently, prevalence & treatment of IGD are topics of interest for clinicians worldwide. The limited literature shows partial response to bupropion and escitalopram. The adolescent in our case responded well to naltrexone. The possible neurobiology, role of opioid receptors and naltrexone in IGD is discussed. Future studies regarding neurobiology and pharmacological treatment of IGD may be considered.Clozapine Resistant Schizophrenia augmented with Electroconvulsive Therapy-a Case ReportDr.B.Ramachandrababu pgDr Ahalya Asst professorDr poornachandrika professorDr pp kannan professor.INTRODUCTION:schizophrenia patients with poor response to antipsychotics and even clozapine need Electro convulsive therapy for augumentation to get adequate therapeutic response.CASE REPORT:Mr S,48yrs male brought by his brother on oct2020 with complaints of talking to self,poor self care,reduced sleep and appetite, withdrawn from others,sudden screaming outbursts,irritability, continues illness from 2013 with waxing and waning course with no significant improvement to antipsychoticson examination Patient ambulant,unkempt and untidy with poor rapport,restricted affect, communicate with gestures,paucity of thought and Auditory hallucinations.His initial BPRS 72 and BUSH FRANCIS catatonic score 26patient treated with Lorazepam and antipsychotics In adequate dose and duration[T.Risperidone 6mg,T.Haloperidol 20 mg,T.Aripiprazole 20 mg,T.Olanzepine 20 mg] shows poor response,later T.Clozapine alone and with atypical antipsychotic augumentation [risperidone and amisulpride] had mild improvement with BPRS 54, BFCS 18.But soon patient relapsedOn Feb 2021,along with clozapine–modified bitemporal Electro convulsive therapy given at 6 sittings.patient shows significant reduction in psychotic and catatonic symptoms with BPRS 32 and BFCS 14 after ECT, another 6 sittings of ect given at august 21, patient shows significant improvement with BPRS18 and BFCS < than 10.so planned maintanance ect initially once in a week for 6 weeks then once in two weeks.Now his catatonic or negative or psychotic symptoms significantly improved.now he helping in ward works,had good self care and goes ITC regularly

Magnetic Seizure Therapy Compared to Electroconvulsive Therapy for Schizophrenia: A Randomized Controlled Trial.

Background: Magnetic seizure therapy (MST) is a potential alternative to electroconvulsive therapy (ECT). However, reports on the use of MST for patients with schizophrenia, particularly in developing countries, which is a main indication for ECT, are limited.Methods: From February 2017 to July 2018, 79 inpatients who met the DSM-5 criteria for schizophrenia were randomized to receive 10 sessions of MST (43 inpatients) or ECT (36 inpatients) over the course of 4 weeks. At baseline and 4-week follow-up, the Positive and Negative Syndrome Scale (PANSS) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) were used to assess symptom severity and cognitive functions, respectively.Results: Seventy-one patients who completed at least half of the treatment protocol were included in the per-protocol analysis. MST generated a non-significant larger antipsychotic effect in terms of a reduction in PANSS total score [g = 0.17, 95% confidence interval (CI) = −0.30, 0.63] and response rate [relative risk (RR) = 1.41, 95% CI = 0.83–2.39]. Twenty-four participants failed to complete the cognitive assessment as a result of severe psychotic symptoms. MST showed significant less cognitive impairment over ECT in terms of immediate memory (g = 1.26, 95% CI = 0.63–1.89), language function (g =1.14, 95% CI = 0.52–1.76), delayed memory (g = 0.75, 95% CI = 0.16–1.35), and global cognitive function (g = 1.07, 95% CI = 0.45–1.68). The intention-to-treat analysis generated similar results except for the differences in delayed memory became statistically insignificant. Better baseline cognitive performance predicted MST and ECT response.Conclusions: Compared to bitemporal ECT with brief pulses and age-dose method, MST had similar antipsychotic efficacy with fewer cognitive impairments, indicating that MST is a promising alternative to ECT as an add-on treatment for schizophrenia.Clinical Trial Registration: ClinicalTrials.gov, identifier: NCT02746965.

The consortium of Researchers for ECT (CORE) - past, present and future

Abstract The Consortium of Researchers for ECT (CORE) was established in 1996 with the goal to conduct multicenter clinical trials in Electroconvulsive Therapy (ECT). The group comprised of four clinical sites: Medical University of South Carolina (MUSC) in Charleston, SC, Mayo Clinic, Rochester MN, University of Texas SW, Dallas TX, and Hillside Hospital, Glen Oaks NY, NY. The database coordinating center was based at MUSC. The CORE group conducted 3 multicenter clinical trials, all funded by the National Institute of Mental health (NIMH). The first study by the group compared the clinical outcomes of 201 patients who were randomly assigned to receive continuation ECT or continuation pharmacotherapy for 6 months after a successful course of bitemporal ECT for major depression. This is the first randomized controlled trial to establish the clinical effectiveness of continuation ECT. The second study by the CORE group, with the addition of the New Jersey Medical School in Newark, NJ and the subtraction of the clinical site of MUSC, compared the effectiveness and tolerability of the 3 most used electrode placements, i.e. bitemporal, bifrontal and right unilateral (RUL) for the treatment of unipolar depression. The study found only numerical but no statistically significant differences in the efficacy and tolerability of the 3 placements with bitemporal slightly more effective than bifrontal and frontal slightly more effective than RUL. The third study by the group, Preventing Relapse in Depressed Elderly (PRIDE) compared the efficacy and tolerability of continuation ECT plus venlafaxine to venlafaxine alone in preventing relapse after acute ECT in geriatric patients. The combination of venlafaxine and continuation ECT was superior to venlafaxine alone. We’ll discuss in detail the primary results of the above studies, as well as additional analyses that have contributed to the shaping of the current clinical practice of ECT. Keywords: Electroconvulsive, Multicenter, Depression, Research Collaboration

Relapse following bitemporal and high-dose right unilateral electroconvulsive therapy for major depression.

Electroconvulsive therapy (ECT) is an effective acute treatment for severe and/or medication-resistant depression but maintaining remission following completion of a course remains a clinical challenge. EFFECT-Dep Trial (ISRCTN23577151) participants with a DSM-IV major depressive episode who met remission criteria after a randomly assigned course of twice-weekly brief-pulse bitemporal (1.5×seizure threshold) or high-dose (6×seizure threshold) right unilateral ECT were monitored for relapse for 12months. In line with the pragmatic trial design, all patients received treatment-as-usual individualised pharmacotherapy during and after ECT; no remitter received continuation ECT. Of 61remitters, 24 (39.3%) relapsed, one (1.6%) withdrew from the study while in remission and the remaining 36 (59.0%) stayed well for a year. Most relapses occurred within the first six months, resulting in a cumulative six-month relapse rate of 31.1%. In a multivariable Cox proportional hazards regression model, older age (p=0.039) and psychotic features at pre-ECT baseline (p=0.037) were associated with a more favourable long-term prognosis while a greater number of previous depressive episodes (p=0.028) and bipolar II (but not bipolar I) diagnosis (p=0.030) were associated with a worse long-term outcome. Electrode placement and medication resistance prior to ECT had no effect on relapse. Adjusting for covariates, fewer patients treated with lithium relapsed in the overall group (p=0.008) and in the unipolar depression subgroup (p=0.027). Long-term outcome following high-dose right unilateral ECT does not differ from bitemporal ECT. Prognosis is particularly favourable in older adults, psychotic depression and patients maintained on lithium.

Factors associated with post-electroconvulsive therapy delirium: A retrospective chart review study.

Although electroconvulsive therapy (ECT) is generally a safe therapeutic method, unexpected adverse effects, such as post-ECT delirium, may occur. Despite its harmful consequences, there has been little discussion about the predictors of post-ECT delirium. Thus, the current study aimed to clarify the factors associated with post-ECT delirium by reviewing electronic medical records of 268 bitemporal ECT sessions from December 2006 to July 2018 in a university hospital.Demographic and clinical characteristics of sessions involving patients with or without post-ECT delirium were compared. Multiple logistic regression analysis was applied to analyze the correlation between variables and post-ECT delirium.Post-ECT delirium developed in 23 sessions (8.6%). Of all the demographic and clinical variables measured, only etomidate use was significantly different between delirium-positive and delirium-negative groups after Bonferroni correction. The regression model also indicated that etomidate use to be significantly associated with post-ECT delirium.In this study, etomidate was associated with a higher risk of developing post-ECT delirium, an association that appeared unrelated to other possible measured variables. Practitioners should take into account the risk of post-ECT delirium while choosing anesthetics, so as to prevent early discontinuation before sufficient therapeutic gain is achieved.

Effect of electrode placement on speed of response to ECT

ObjectiveElectroconvulsive therapy (ECT) can be rapidly effective in treating severe depression. Right unilateral (RUL) or bitemporal (BT) electrode placement may affect the speed of ECT effectiveness although our current understanding of demographic and clinical factors for predicting predict speed of response and remission with ECT is limited. We investigated differences in improvement speed and also time to achieving response and remission criteria between brief-pulse moderate-dose (1.5 x seizure threshold) BT ECT and high-dose (6 x seizure threshold) RUL ECT. Additionally, we explored the influence of demographic and clinical characteristics.MethodsSe analysed weekly 24-item Hamilton Depression Rating Scale scores obtained from severely depressed patients participating in the EFFECT-Dep trial (ISRCTN23577151). Improvement speeds in patients treated randomly with a course of either BT (n = 69) or RUL ECT (n = 69) were compared using independent sample t-tests. Weekly proportions of responders and remitters were compared using chi-square tests. Cox regression analyses were used to explore predictors of speed to achieve response and remission status.ResultsSe found no differences between RUL and BT ECT in speed of improvement or time to achieve response or remission. Exploratory analyses indicated that a wide variety of demographic and clinical features did not serve to predict speed of response and remission to ECT.ConclusionElectrode placement did not substantially influence speed of improvement, response and remission with twice-weekly brief-pulse ECT. Minimising the cognitive side-effects of ECT may be of more relevance when choosing between BT and RUL electrode placement for ECT.DisclosureDeclan M. McLoughlin has received speaker’s honoraria from Mecta and Otsuka and an honorarium from Janssen for participating in an esketamine advisory board meeting. The other author reports no conflicts of interest. This work was supported by awards from

A Case of Successful Ketamine Treatment after ECT Failure in a patient with Major Depressive Disorder

<h3>Introduction</h3> Electroconvulsive therapy (ECT) has long been a treatment modality of choice for treatment resistant depression. It remains one of the most effective treatments in psychiatry for a multitude of diseases. However, if patients fail ECT there is a lack of robust options for alternative treatments. This case describes a patient who was initially treated with ECT with no response after several treatments and subsequently transitioned to IV ketamine. Once started on ketamine patient showed a significnat improvement in his depressive symptoms and was able to be discharged from an inpatient psychiatric unit. Mr. X is a 70 year old male with a history of major depressive disorder and three prior suicide attempts. He had multiple recent life stressors, including a spouse diagnosed with cancer and being unable to work after back surgery which significantly contributed to his depression. He was admitted to the psychiatric hospital after an attempted overdose. He was started on escitalopram and buproprion XL, which were titrated to max doses throughout his hospitalization. Given his history of incomplete response with medication, his severe depression, and his high suicide risk, aggressive treatment was warranted. ECT was initiated and he underwent 5 treatments of right unilateral, 2 treatments of bifrontal, and 1 treatment of bitemporal. Throughout the course of ECT he had a lack of seizures despite flumazenil, hyperventilation, various induction agents (including ketamine) and pharmacology. During that time he was not getting out of bed, reporting consistently depressed mood, amotivated, and apathetic. He also began noticing some increased cognitive difficulties with the bifrontal and bitemporal ECT treatments. He ultimately was deemed an ECT failure after 8 treatments with no response. Given his continued depression and failure of ECT, it was decided to attempt IV ketamine infusions as the next intervention for his depression. <h3>Methods</h3> A literature review was conducted searching for Ketamine vs ECT treatment for depression and suicidality using MESH terms of "(Depression) AND (Suicidal behavior) AND (Electroconvulsive therapy OR Electroshock therapy OR Shock therapy OR Electroshock OR Shock treatment OR Convulsive therapy OR Electric shock therapy OR Electric Convulsive therapy OR ECT) AND Ketamine" and "(Depression) AND (Suicidality) AND (Electroconvulsive therapy OR Electroshock therapy OR Shock therapy OR Electroshock OR Shock treatment OR Convulsive therapy OR Electric shock therapy OR Electric Convulsive therapy OR ECT) AND Ketamine." Additional literature regarding Ketamine for treatment resistant depression was searched for using MESH terms of "(Ketamine OR CI-581 OR CI 581 OR CI581 OR Ketalar OR Ketaset OR Ketanest OR Calipsol OR Kalipsol OR Calypsol) AND (therapy OR medical plan OR treatment OR regimen) AND (treatment resistant depression OR therapy resistant depression OR TRD OR refractory depression)." <h3>Results</h3> After initiation of ketamine Mr. X noticed an immediate improvement. He was given 3 total treatments while inpatient with significant clinical improvment noted after each treatment. He was noted to be more engaged, had improved eye contact, and was reporting improvment in his mood. He was also more active, and was noted to be consistently out of bed ambulating with his walker. After the 3 treatments inpatient he was deemed psychiatrically stable for discharge with the plan to continue an acute course of treatment post discharge. He received 2 more treatments after discharge as an outpatient before ultimately being lost to follow up. Electroconvulsive Therapy continues to show a robust response rate of approximately 80%, with remission in about 75% of cases. Even with these response rates, there is a significant patient population that will not respond to ECT. Research has shown that ketamine can have an immediate response of up to or greater than 70% of patietns within the 24 hours post-infusion. Duration of response is varied, though has been found to be present in about 50–70% of patients. However, there has not been significant published research looking into response to ketamine post ECT failure. <h3>Conclusions</h3> Mr. X is a prime example of the ongoing difficulties in treating patients with treatment resistant depression who do not respond to ECT. This case shows that after ECT failure it is appropriate to attempt treatment with ketamine barring the patient having any contraindications for treatment. Given that there is little published data regarding the response of patients who have failed ECT but subsequently respond to ketamine infusions, this case is an attempt to add to the literature in that regard. <h3>Funding</h3> None

Speed of electroconvulsive therapy for depression: Effects of electrode placement.

Electroconvulsive therapy (ECT) is a rapidly effective treatment for severe depression. Treatment with right unilateral (RUL) or bitemporal (BT) ECT may explain individual differences in speed of ECT effectiveness. There is limited evidence for demographic and clinical factors that predict speed of response and remission with ECT. We aimed to investigate differences in speed of improvement as well as achieving response and remission between twice-weekly brief-pulse high-dose (6 × seizure threshold) RUL ECT and moderate-dose (1.5 × seizure threshold) BT ECT. We also explored demographic and clinical characteristics that predict speed of response and remission. Weekly 24-item Hamilton Depression Rating Scale scores were assessed among patients with severe depression who participated in the EFFECT-Dep trial (ISRCTN23577151). Speed of improvement in patients randomised to RUL ECT (n=69) or BT ECT (n=69) was compared using independent sample t tests. Pearson's chi-square and Fisher's exact tests compared proportions of responders and remitters at each weekly assessment. Predictors of speed of response and remission were explored using Cox regression analyses. There were no significant differences between RUL and BT ECT in speed of improvement, response or remission. Exploratory analyses indicated that speed of response and remission were not predicted by a wide variety of demographic and clinical characteristics. ECT electrode placement did not have predictive value when determining speed of improvement, response and remission with ECT. Other clinical factors, such as cognitive side-effects, may be more relevant when making the clinical choice between RUL and BT ECT.

Comparison of the target-controlled infusion and the manual infusion of propofol anesthesia during electroconvulsive therapy: an open-label randomized controlled trial

BackgroundTarget-controlled infusion (TCI) of propofol is a well-established method of procedural sedation and has been used in Japan for anesthesia during electroconvulsive therapy (ECT). However, the usefulness of the TCI of propofol for ECT has yet to be determined. This study aimed to compare the TCI and manual infusion (MI) of propofol anesthesia during ECT.MethodsA total of forty psychiatric inpatients receiving bitemporal ECT were enrolled in the present study and randomized into the TCI group (N = 20) and the MI group (N = 20). Clinical Global Impression (CGI) and Montreal Cognitive Assessment (MoCA) scores were measured before and after ECT. The clinical outcomes, anesthesia-related variables, and ECT-related variables were compared between the two groups. Generalized estimating equations (GEEs) were used to model the comparison throughout the course of ECT.ResultsA total of 36 subjects completed the present study, with 18 subjects in each group. Both the groups didn’t significantly differ in the post-ECT changes in CGI and MoCA scores. However, concerning MoCA scores after 6 treatments of ECT, the MI group had improvement while the TCI group had deterioration. Compared with the MI group, the TCI group had higher doses of propofol, and longer procedural and recovery time. The TCI group seemed to have more robust seizures in the early course of ECT but less robust seizures in the later course of ECT compared with the MI group.ConclusionsThe present study does not support the use of TCI of propofol for anesthesia of ECT.Trial registration(ClinicalTrials.gov): NCT03863925. Registered March 5, 2019 - Retrospectively registered.

Is There Evidence That Stimulus Parameters and Electrode Placement Affect the Cognitive Side Effects of Electroconvulsive Therapy in Patients With Schizophrenia and Schizoaffective Disorder?: A Systematic Review.

Seventy percent of patients with treatment-resistant schizophrenia do not respond to clozapine. Electroconvulsive therapy (ECT) can potentially offer significant benefit in clozapine-resistant patients. However, cognitive side effects can occur with ECT and are a function of stimulus parameters and electrode placements. Thus, the objective of this article is to systematically review published clinical trials related to the effect of ECT stimulus parameters and electrode placements on cognitive side effects. We performed a systematic review of the literature up to July of 2020 for clinical studies published in English or German examining the effect of ECT stimulus parameters and/or electrode placement on cognitive side effects in patients with schizophrenia or schizoaffective disorder. The literature search generated 3 randomized, double-blind, clinical trials, 1 randomized, nonblinded trial, and 1 retrospective study. There are mixed findings regarding whether pulse width and stimulus dose impact on cognitive side effects. One study showed less cognitive side effect for right unilateral (RUL) than bitemporal (BT) electrode placement, and 2 studies showed a cognitive advantage for bifrontal (BF) compared with BT ECT. Only 1 retrospective study measured global cognition and showed post-ECT cognitive improvement with all treatment modalities using Montreal Cognitive Assessment in comparison to pre-ECT Montreal Cognitive Assessment scores. Current data are limited, but evolving. The evidence suggests that RUL or BF ECT have more favorable cognitive outcomes than BT ECT. Definitive larger clinical trials are needed to optimize parameter and electrode placement selection to minimize adverse cognitive effects.