Electroconvulsive Therapy For Depression Research Articles

Is Electroconvulsive Therapy for Depression More Effective Than Placebo? A Systematic Review of Studies Since 2009

Background:A 2010 review of studies, previous reviews and meta-analyses found minimal evidence that electroconvulsive therapy (ECT) for depression was more effective than placebo during the treatment period and no evidence at all of efficacy beyond the end of treatment. The current review explored whether any contradictory evidence has since been generated.Method:MEDLINE and PsycINFO were searched to identify all post-2009 studies that had compared ECT and simulated ECT for depression, or had in any other way generated valid depression data for ECT recipients at two or more points in time.Results:Ninety-one studies met inclusion criteria. There were no new placebo-controlled trials. There have now been no such studies since 1985. Only 4 placebo-controlled studies have ever produced data beyond the end of treatment, none of which have found any advantage for ECT over placebo. Of the 91 studies, only 2 aimed to evaluate the efficacy of ECT. Both were severely flawed. None of the other 89 produced robust evidence that ECT is effective for depression, primarily because at least 60% maintained ECT participants on medication and 89% produced no meaningful follow-up data beyond the end of treatment. No studies investigated whether ECT prevents suicide.Conclusions:There is still no evidence that ECT is more effective than placebo for depression reduction or suicide prevention. Given the well-documented high risk of persistent memory dysfunction, the cost-benefit analysis for ECT remains so poor that its use cannot be scientifically, or ethically, justified.

Cerebellar volume change in response to electroconvulsive therapy in patients with major depression

Electroconvulsive therapy (ECT) is remarkably effective in severe major depressive disorder (MDD). Growing evidence has accumulated for brain structural and functional changes in response to ECT, primarily within cortico-limbic regions that have been considered in current neurobiological models of MDD. Despite increasing evidence for important cerebellar contributions to affective, cognitive and attentional processes, investigations on cerebellar effects of ECT in depression are yet lacking. In this study, using cerebellum-optimized voxel-based analysis methods, we investigated cerebellar volume in 12 MDD patients who received right-sided unilateral ECT. 16 healthy controls (HC) were included. Structural MRI data was acquired before and after ECT and controls were scanned once. Baseline structural differences in MDD compared to HC were located within the “cognitive cerebellum” and remained unchanged with intervention. ECT led to gray matter volume increase of left cerebellar area VIIa crus I, a region ascribed to the “affective/limbic cerebellum”. The effects of ECT on cerebellar structure correlated with overall symptom relief. These findings provide preliminary evidence that structural change of the cerebellum in response to ECT may be related to the treatment's antidepressant effects.

Predictors of readmission after successful electroconvulsive therapy for depression: a chart review study

Objective: The study aimed to identify the predictors for readmission after a successful electroconvulsive therapy (ECT) course.Methods: Medical charts of patients who received ECT for major depressive episodes were reviewed. Patients’ demographic characteristics and treatment parameters, such as ECT charge, seizure duration, the number of ECT sessions and pharmacotherapy, were extracted. We compared differences between those who were readmitted after successful ECT within 6 and 12 months, versus those not readmitted. We also conducted a multivariate logistic regression analysis to identify the predictors for readmission.Results: Out of 51 patients who were discharged after ECT, 27 patients met the inclusion criteria and were included in the analysis. Eight patients were readmitted within 6 months after discharge, and four more patients were readmitted during the next 6-month follow up. Comparing patients who were and were not readmitted, we found no significant differences between groups, including ECT parameters such as the number of ECT sessions, average charge and final charge. No predictors for readmission were found through multivariate analysis.Conclusions: Although patients who require higher ECT charge and more sessions seem to be prone to readmission, our dataset suggested that none of these types of ECT parameters were risk factors for readmission.

Ketamine for depression relapse prevention following electroconvulsive therapy: protocol for a randomised pilot trial (the KEEP-WELL trial).

BackgroundMajor depressive disorder is a common debilitating illness that is the second leading contributor to the global burden of disease. Unfortunately, about 30 % of patients do not respond to adequate trials of antidepressants and/or psychotherapies. About 45–60 % of such treatment-resistant patients will remit with electroconvulsive therapy (ECT). However, relapse rates are high following ECT—38 % after 6 months. There is a need for better relapse prevention strategies. One possibility is to use ketamine, a competitive glutamate receptor antagonist used for anaesthesia. A recent paradigm shift in treating depression and understanding its biology has been the finding that ketamine has a robust, rapid-onset, though short-lived, antidepressant effect that is possibly mediated through neuroplastic effects. However, ketamine has not previously been reported on for relapse prevention.Methods/designThe main objective of this study is to conduct a randomised controlled pilot trial (n = 40) of a 4-week course of once-weekly ketamine infusions for relapse prevention following ECT for depression to assess trial procedures that will inform a future definitive trial. Participants with unipolar depression will be recruited prior to commencing ECT and be assessed weekly during the ECT course using the primary clinical outcome, the 24-item Hamilton Rating Scale for Depression (HRSD-24). Those who meet standard response criteria will be invited, on completing ECT, to be randomised in a 1:1 ratio to a course of four once-weekly infusions of ketamine or an active comparator midazolam, which mimics some of the effects of ketamine and may improve blinding over inactive placebo. Participants will be followed up over 6 months using the HRSD-24 to assess for relapse.DiscussionThis is the first registered trial (NCT02414932, https://clinicaltrials.gov/ct2/show/NCT02414932) of ketamine for depression relapse prevention, an important possible use of this agent. The primary focus of the pilot trial is on feasibility. However, a 95 % confidence interval will be determined for the difference between ketamine and midazolam groups in 6-month relapse rates to help inform a future definitive trial.Trial registration https://clinicaltrials.gov/ NCT02414932Secondary Identifying numbers:EudraCT number: 2014-000339-18Sponsors’ Reference, Sponsor: St. Patrick’s Mental Health Services: 05/14Research Ethics Committee Reference, Joint REC of St James’ and Tallaght Hospitals, Dublin: 2014-08-19Electronic supplementary materialThe online version of this article (doi:10.1186/s40814-016-0080-0) contains supplementary material, which is available to authorized users.

Electroconvulsive therapy for depression in Parkinson's disease: systematic review of evidence and recommendations.

We performed a systematic review of evidence regarding treatment of depression in Parkinson's disease (PD) utilizing electroconvulsive therapy. The search led to the inclusion of 43 articles, mainly case reports or case series, with the largest number of patients totaling 19. The analysis included 116 patients with depression and PD; depression improved in 93.1%. Where motor symptoms' severity was reported, 83% of patients improved. Cognition did not worsen in the majority (94%). Many patients experienced delirium or transient confusion, sometimes necessitating discontinuation of electroconvulsive therapy (ECT). Little is known about maintenance ECT in this population. ECT can benefit patients suffering from PD and depression. We recommend an algorithm for treatment of depression in PD, utilizing ECT sooner rather than later.

High-Dose, Unilateral ECT Found as Effective as Bilateral ECT

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessHigh-Dose, Unilateral ECT Found as Effective as Bilateral ECTMark MoranMark MoranSearch for more papers by this authorPublished Online:11 Mar 2016https://doi.org/10.1176/appi.pn.2016.3b8AbstractThe study appears as the Food and Drug Administration is considering reclassifying ECT from a “high-risk” to a “low-risk” medical device, a change that APA supports.Twice-weekly high-dose unilateral electroconvulsive therapy (ECT) appears to be no less effective than bitemporal ECT for depression and may be preferable because of its better cognitive side-effect profile, according to a report in the February 19 AJP in Advance.Maria Semkovska, Ph.D., of the Department of Psychiatry at Trinity College Dublin and colleagues reported on the results of EFFECT-Dep (Enhancing the Effectiveness of Electroconvulsive Therapy in Severe Depression). The trial was a randomized, “non-inferiority” trial with a six-month follow-up to determine whether high-dose unilateral ECT was inferior to the more standard bitemporal ECT for severe depression in routine practice over six months. One-hundred and thirty-eight participants were randomly assigned to bitemporal or high-dose unilateral ECT. Participants were inpatients recruited between May 2008 and October 2012 from St. Patrick’s Mental Health Services, an independent nonprofit organization that provides national services and runs Ireland’s largest ECT clinic“Seizure threshold”—the minimum charge required to induce the generalized seizure needed for therapeutic effect—was established by dose titration at the first session, and subsequent treatments were 1.5 times this threshold for bitemporal ECT and six times this threshold for unilateral ECT. In line with regular practice, the number of ECT sessions was determined by referring clinicians in consultation with patients, with up to 12 sessions in accordance with recommendations of the Irish Mental Health Commission The primary outcome was change in the 24-item Hamilton Rating Scale for Depression (HAM-D) score after the ECT course. A pre-specified range of a four-point difference in either direction was established as the range within which the treatment would be considered “non-inferior.”Secondary depression outcomes included HAM-D scores at the three- and six-month follow-ups, end-of-treatment remission and response status, and relapse status for remitters during the six-month follow-up. Remission was defined as 60 percent or greater decrease from the baseline HAM-D score and a score of 10 or less for two consecutive weeks; response was defined as a 60 percent or more decrease from the baseline HAM-D score and a score of 16 or less; and relapse was defined as a HAM-D score of 16 or more for two consecutive weeks.The researchers found that high-dose unilateral ECT was not inferior to bitemporal ECT on HAM-D scores, with a mean difference of 1.08 points in favor of unilateral ECT (within the range of “non-inferiority”). There were no significant differences for response and remission or six-month relapse status. Recovery of orientation was quicker following unilateral ECT, and bitemporal ECT was associated with a lower percent recall of autobiographical information.The study appears as the Food and Drug Administration (FDA) is proposing to reclassify ECT from a Class III (high-risk) medical device to Class II (low-risk), a change APA supports. Comments on the proposal were due March 28.Semkovska and colleagues say the AJP study has important clinical implications. “In terms of harms/benefits ratio, high-dose unilateral ECT was non-inferior to bitemporal ECT but showed a better cognitive profile, especially for preserving retrograde personal memories and fewer subjective cognitive side effects,” they wrote.“While there is much interest in other modifications to maintain effectiveness but reduce side effects (such as ultra-brief pulse-width ECT), these require further refinement and characterization for optimization. Our findings justify considering high-dose unilateral ECT as the preferred ECT option for treating depression and may help improve acceptability and availability of this effective treatment.” ■“Bitemporal Versus High-Dose Unilateral Twice-Weekly Electroconvulsive Therapy for Depression (EFFECT-Dep): A Pragmatic, Randomized, Non-Inferiority Trial” can be accessed here. ISSUES NewArchived

ID 25 – Changes of cardiac autonomic nervous activity during a course of electroconvulsive therapy in depression

Objective Seizure duration has been reported to decrease across a course of electroconvulsive therapy (ECT) (anticonvulsant effect). Because dynamic autonomic activity changes have been described during ECT, and are affected by seizure generalization, we examined the relationship between longitudinal autonomic nervous activity changes on a course of ECT and seizure duration. Methods Electroencephalograms (EEG) and electrocardiograms (ECG) of twelve depressive patients were recorded during ECT procedures. The mean heart rate (HR) in 30 s prior to stimulus onset was defined as baseline HR. The T Max peak was designated as the data point with the maximum HR after stimulus onset. T 1/2 points were determined as the time point when HR was reduced midway between baseline HR and T Max HR. The changes of EEG seizure duration, T Max , and T 1/2 throughout the course of ECT, and their correlations, were examined. Results T 1/2 significantly decreased with repetition of ECT. T 1/2 was positively correlated to EEG seizure duration. Conclusions The time to return to the baseline from sympathetic nervous activation caused by ECT stimulation is shortened during a course of ECT. Key message Sympathetic nervous activity suppression and an anticonvulsant effect may contribute to the clinical action of ECT.

S.05.03 Cognitive-behavioural therapy as continuation treatment to sustain response after electroconvulsive therapy in depression (NCT00437385)

S.05.03 Cognitive-behavioural therapy as continuation treatment to sustain response after electroconvulsive therapy in depression (NCT00437385)

Effect of Ketamine, Thiopental and Ketamine-Thiopental Combination during Electroconvulsive Therapy for Depression.

We aimed to evaluate the effect of anaesthesia with thiopental (4 mg kg(-1)), ketamine (1 mg kg(-1)) and ketamine-thiopental (1 mg kg(-1) and 4 mg kg(-1), respectively) combination during electroconvulsive therapy (ECT) on the Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HAM-A) and haemodynamic variables in patients with resistant major depression. Patients with HDRS scores above 17 were included. The patients were randomly divided into three groups according to the anaesthesia used. Group 1 was given thiopental (4 mg kg(-1)), Group 2 was given ketamine (1 mg kg(-1)) and Group 3 was given ketamine (1 mg kg(-1)) and thiopental (4 mg kg(-1)). Succinylcholine (1 mg kg(-1)) was administered in all patients for muscle relaxation. HDRS and HAM-A scores were evaluated before ECT, after 3, 6. ECT and after the final ECT. Systolic and diastolic blood pressures, heart rates and oxygen saturations were recorded before and after anaesthesia induction and after the ECT procedure. Seizure duration was recorded. Fifty-eight patients were included in the study. Thirty (52%) patients were male and 28 (48%) were female. The mean age was 42.7±15.8 years in Group 1, 44.8±11 years in Group 2 and 38.6±6.8 years in Group 3. In all groups, HDRS scores were reduced compared with the baseline values. There was no statistical significant difference between the groups regarding HDRS scores. HAM-A scores were higher in Group 2 and Group 3. Systolic and diastolic blood pressures and heart rate values were lower in Group 1 and the difference was statistically significant. In this study, anaesthesia induced with thiopental, ketamine and thiopental-ketamine combination was observed to not result in a difference in ECT for patients with treatment-resistant depression. Ketamine at a dose of 1 mg kg(-1) given just before ECT did not enhance the antidepressant effect of ECT; however, anxiety scores were increased with ketamine application.

A systematic review and meta-analysis of brief vs ultrabrief right unilateral electroconvulsive therapy for depression

A systematic review and meta-analysis of brief vs ultrabrief right unilateral electroconvulsive therapy for depression

Improving relapse prevention after successful electroconvulsive therapy for patients with severe depression: completed audit cycle involving 102 full electroconvulsive therapy courses in West Sussex, United kingdom.

The aim of this study was to determine whether current guidance or consensus regarding continuation pharmacotherapy after successful electroconvulsive therapy (ECT) was being followed by referring clinicians in West Sussex, United Kingdom. A complete audit cycle examining psychotropic medication after successful ECT for patients with severe depression was performed. Clinical and ECT records (electronic and paper) were reviewed, and relapse rates in the 4 commonly prescribed psychotropic medication groups were compared. The pattern of relapse in the 4 groups was similar for both audits 1 and 2. Taking the 102 patients as a whole, the lowest relapse rates were recorded for patients taking a combination of an antidepressant and lithium (16% relapsed within 6 months of successful ECT). Patients taking a combination of antipsychotic and antidepressants fared the worst with 75% relapse rate. This was followed by those taking a combination of antidepressant and a mood stabilizer (other than lithium) (69%). Patients taking antidepressant(s) only were associated with a relapse rate of 60%. Audit 2 demonstrated that clinicians did not change their prescribing practices for their patients after successful ECT despite the efforts made in widely disseminating the results of audit 1. In particular, there was no increase in the use of lithium. Not all psychotropic medication prescribing for patients receiving ECT for depression followed available and current guidance or consensus. More needs to be done to understand the reasons for the reluctance to use lithium if relapse rates after ECT are to improve.

P.2.b.014 Modulation of limbic–prefrontal connectivity by electroconvulsive therapy in depression: a structural equation modeling approach

P.2.b.014 Modulation of limbic–prefrontal connectivity by electroconvulsive therapy in depression: a structural equation modeling approach

Electroconvulsive therapy in depression: insights from fMRI, PET and SPECT studies

Electroconvulsive therapy (ECT) is the most potent and rapidly acting of all antidepressant treatments in major depressive disorder (MDD). Nuclear and functional magnetic (fMRI) brain imaging studies of ECT have substantially contributed to the neurobiological understanding of this treatment modality. Neuroimaging methods may also validate potential mechanisms of antidepressant action. Models of neural dysfunction in MDD suggest impaired modulation of activity within a cortico-limbic circuitry, along with alterations in the functional organisation of multiple brain networks implicated in emotional processes. Nuclear imaging techniques have demonstrated consistent patterns of ECT-induced ictal changes in brain activity that appear to be linked to efficacy and side effects of ECT. Interictally, widespread alterations of brain function have been reported, however, results remain inconclusive. FMRI studies of ECT have demonstrated longer-lasting, interictal changes of neural activity in multiple cerebral regions that are in accordance with functional neuroanatomical models of mood disorders. Future research detailing ECT interactions with brain pathophysiology in MDD could potentially provide a clinically useful framework to better predict ECT treatment response and/or side effects, and may also facilitate the development of more focused brain stimulation techniques.

Modulation of interhemispheric functional coordination in electroconvulsive therapy for depression.

Considerable evidence suggests that depression is related to interhemispheric functional coordination deficits. For depression, electroconvulsive therapy (ECT) is the most rapid and effective therapy, but its underlying mechanism remains unknown. The aim of this study was to explore the impact of ECT on the interhemispheric functional coordination in depression patients. We used resting-state functional magnetic resonance imaging to observe the change of interhemispheric functional coordination with the method of voxel-mirrored homotopic connectivity (VMHC) in 11 depressed patients before and after ECT, compared with 15 healthy controls. The results showed that, compared with depression patients before ECT, VMHC was significantly increased in superior frontal gyri (BA 8), middle frontal gyri (two clusters: BA 8/9 and BA 10) and angular gyri (BA 39) in depression patients after ECT. Compared with healthy controls, VMHC in those areas was significantly lower in the middle frontal gyri (BA 8/9) and angular gyri (BA 39) in depression patients before ECT, but no significant difference was observed in the superior frontal gyri (BA 8) and middle frontal gyri (BA 10). There was no significant correlation between the changes of Hamilton Depression Rating Scale scores and changed VMHC values in those four areas in depression patients. The results suggest that ECT selectively modulated interhemispheric functional coordination in depression patients. Such may play an important mechanistic role in the treatment of depression, and may afford a useful avenue for optimizing treatment.

The Immune System and Electroconvulsive Therapy for Depression

Electroconvulsive therapy (ECT) remains the most effective and fast-acting treatment option for several psychiatric conditions, including treatment-resistant depression. Although ECT has been in use for 75 years, the mechanism of action is unknown. There is emerging evidence that modulation of the hypothalamic-pituitary-adrenal axis may mediate, in part, the therapeutic action of ECT. A growing body of evidence points to links between disturbances in the immune system and depression. However, the impact of ECT on immune functioning and the possible role of alterations in the immune system as a mechanism of action of ECT remain elusive. To provide a literature overview on the effects of ECT on the immune system. Relevant articles and abstracts in English were retrieved from PubMed/Medline using search terms related to ECT, inflammation, and immune system. The results of studies examining ECT-induced changes in immune functioning as well as the degree to which these represent possible mechanisms mediating the therapeutic action of ECT were summarized. Our search identified only a limited number of studies. The findings suggest that a single session of ECT induces an acute, transient immune activation, whereas repetitive ECT treatment results in long-term down-regulation of immune activation. However, inconsistency in findings and methodological issues, including sample size and lack of consideration of confounding factors affecting cytokine concentrations, precludes definitive conclusion. To elucidate the possible role of immunological changes mediating the effect of ECT, more prospective controlled studies with larger sample sizes are required.

Electroconvulsive Therapy for Depression in a Nursing Home Resident With Frontotemporal Dementia

Depression is common in dementia and long term care residents. Clinicians overlook depression in the long term care setting, as detection and management may be made difficult by co-existing cognitive impairment and medical comorbidities. Even when appropriately identified, the evidence for efficacy of pharmacologic treatments for depression in this population is limited, with one study of 98 patients with Alzheimer's or vascular dementia showing a statistically significant reduction in mood symptoms at 4 weeks with 10-30 mg daily of citalopram, but no studies investigating anti-depressant use in frontotemporal dementia (FTD).

Postictal Confusion Was Associated with Improvement After Electroconvulsive Therapy in Depression

Postictal Confusion Was Associated with Improvement After Electroconvulsive Therapy in Depression

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.

Cognitive-Behavioral Therapy as Continuation Treatment to Sustain Response After Electroconvulsive Therapy in Depression: A Randomized Controlled Trial

Although electroconvulsive therapy (ECT) is the most effective acute antidepressant intervention, sustained response rates are low. It has never been systematically assessed whether psychotherapy, continuation ECT, or antidepressant medication is the most efficacious intervention to maintain initial treatment response. In a prospective, randomized clinical trial, 90 inpatients with major depressive disorder (MDD) were treated with right unilateral ultra-brief acute ECT. Electroconvulsive therapy responders received 6 months guideline-based antidepressant medication (MED) and were randomly assigned to add-on therapy with cognitive-behavioral group therapy (CBT-arm), add-on therapy with ultra-brief pulse continuation electroconvulsive therapy (ECT-arm), or no add-on therapy (MED-arm). After the 6 months of continuation treatment, patients were followed-up for another 6 months. The primary outcome parameter was the proportion of patients who remained well after 12 months. Of 90 MDD patients starting the acute phase, 70% responded and 47% remitted to acute ECT. After 6 months of continuation treatment, significant differences were observed in the three treatment arms with sustained response rates of 77% in the CBT-arm, 40% in the ECT-arm, and 44% in the MED-arm. After 12 months, these differences remained stable with sustained response rates of 65% in the CBT-arm, 28% in the ECT-arm, and 33% in the MED-arm. These results suggest that ultra-brief pulse ECT as a continuation treatment correlates with low sustained response rates. However, the main finding implicates cognitive-behavioral group therapy in combination with antidepressants might be an effective continuation treatment to sustain response after successful ECT in MDD patients.

Hippocampal volume in relation to clinical and cognitive outcome after electroconvulsive therapy in depression

ObjectiveIn a previous magnetic resonance imaging (MRI) study, we found a significant increase in hippocampal volume immediately after electroconvulsive therapy (ECT) in patients with depression. The aim of this study was to evaluate hippocampal volume up to 1 year after ECT and investigate its possible relation to clinical and cognitive outcome.MethodClinical and cognitive outcome in 12 in-patients with depression receiving antidepressive pharmacological treatment referred for ECT were investigated with the Montgomery–Asberg Depression Rating Scale (MADRS) and a broad neuropsychological test battery within 1 week before and after ECT. The assessments were repeated 6 and 12 months after baseline in 10 and seven of these patients, respectively. Hippocampal volumes were measured on all four occasions with 3 Tesla MRI.ResultsHippocampal volume returned to baseline during the follow-up period of 6 months. Neither the significant antidepressant effect nor the significant transient decrease in executive and verbal episodic memory tests after ECT could be related to changes in hippocampal volume. No persistent cognitive side effects were observed 1 year after ECT.ConclusionThe immediate increase in hippocampal volume after ECT is reversible and is not related to clinical or cognitive outcome.