Postictal Suppression Index Research Articles

Effect of quantitative consciousness index on seizure parameters during electroconvulsive therapy in patients with major depressive disorder

BACKGROUND Electroconvulsive therapy (ECT) is both an effective treatment for patients with major depressive disorder (MDD) and a noxious stimulus. Although some studies have explored the effect of sedation depth on seizure parameters in ECT, there is little research on the noxious stimulation response to ECT. In this study, we used two electroencephalography (EEG)-derived indices, the quantitative consciousness (qCON) index and quantitative nociceptive (qNOX) index, to monitor sedation, hypnosis, and noxious stimulation response in patients with MDD undergoing acute ECT. AIM To evaluate the effect of anesthesia depth based on the qCON and qNOX indices on seizure parameters. METHODS Patients with MDD (n = 24) underwent acute bilateral temporal ECT under propofol anesthesia. Before ECT, the patients were randomly divided into three groups according to qCON scores (qCON60-70, qCON50-60, and qCON40-50). Continuous qCON monitoring was performed 3 minutes before and during ECT, and the qCON, qNOX, vital signs, EEG seizure parameters, and complications during the recovery period were recorded. The 24-item Hamilton Rating Scale for Depression, Zung’s Self-rating Depression Scale, and Montreal Cognitive Assessment scores were evaluated before the first ECT session, after the fourth ECT session, and after the full course of ECT. RESULTS A total of 193 ECT sessions were performed on 24 participants. The qCON index significantly affected the EEG seizure duration, peak mid-ictal amplitude, and maximum heart rate during ECT (P < 0.05). The qNOX index significantly affected the post-ictal suppression index (P < 0.05). Age, number of ECT sessions, and anesthetic-ECT time intervals also had a significant effect on EEG seizure parameters (P < 0.05). However, there were no significant differences in complications, 24-item Hamilton Rating Scale for Depression scores, Zung’s Self-rating Depression Scale scores, or Montreal Cognitive Assessment scores among the three groups (P > 0.05). CONCLUSION Electrical stimulation at a qCON index of 60-70 resulted in better EEG seizure parameters without increasing complications in patients with MDD undergoing bilateral temporal ECT under propofol anesthesia.

Correlation Between ECT Quality Measures and Likelihood to Transition From Acute to Continuation and Maintenance ECT.

To evaluate the association between 3 ECT quality measures (seizure duration, Postictal Suppression Index [PSI], and heart rate response) and therapeutic compliance as indicated by transitioning from acute to continuation to maintenance phases of ECT. This was a retrospective chart review of patients who received ECT between July 2016 and July 2019. ECT quality measures were lagged by 1 ECT session to examine the effect of the prior session's quality measure on progressing to a higher ECT phase at the subsequent ECT session. Associations with therapeutic compliance were analyzed using mixed-effects ordinal regression and mixed-effects partial proportional odds models. Seizure duration was associated with 8% higher adjusted odds of progressing to out of the acute phase (95% confidence interval [CI]: 2% to 15%, P = 0.007) and 18% higher adjusted odds of progressing to the maintenance phase (95% CI: 10% to 28%, P < 0.001); PSI was associated with 9% higher adjusted odds of progressing out of the acute phase (95% CI: 3% to 16%, P = 0.005), whereas heart rate response was not statistically associated with therapeutic compliance. Greater therapeutic compliance was also associated with bilateral electrode placement and older age. Longer seizure duration was associated with greater therapeutic compliance across all ECT phases, PSI was associated with progressing out of the acute phase, and heart rate response was not associated with therapeutic compliance. Our findings assist ECT psychiatrists in optimizing ECT quality measures to promote better compliance with ECT.

Towards a network control theory of electroconvulsive therapy response.

Electroconvulsive Therapy (ECT) is arguably the most effective intervention for treatment-resistant depression. While large interindividual variability exists, a theory capable of explaining individual response to ECT remains elusive. To address this, we posit a quantitative, mechanistic framework of ECT response based on Network Control Theory (NCT). Then, we empirically test our approach and employ it to predict ECT treatment response. To this end, we derive a formal association between Postictal Suppression Index (PSI)-an ECT seizure quality index-and whole-brain modal and average controllability, NCT metrics based on white-matter brain network architecture, respectively. Exploiting the known association of ECT response and PSI, we then hypothesized an association between our controllability metrics and ECT response mediated by PSI. We formally tested this conjecture in N = 50 depressive patients undergoing ECT. We show that whole-brain controllability metrics based on pre-ECT structural connectome data predict ECT response in accordance with our hypotheses. In addition, we show the expected mediation effects via PSI. Importantly, our theoretically motivated metrics are at least on par with extensive machine learning models based on pre-ECT connectome data. In summary, we derived and tested a control-theoretic framework capable of predicting ECT response based on individual brain network architecture. It makes testable, quantitative predictions regarding individual therapeutic response, which are corroborated by strong empirical evidence. Our work might constitute a starting point for a comprehensive, quantitative theory of personalized ECT interventions rooted in control theory.

Differences in Cognitive Adverse Effects and Seizure Parameters Between Thiopental and Propofol Anesthesia for Electroconvulsive Therapy.

Electroconvulsive therapy (ECT) is a well-established treatment option in case of severe and treatment-resistant psychiatric conditions. In this retrospective study, we compared the 2 anesthetics propofol and thiopental in terms of seizure quality, cognitive adverse effects, and clinical outcome. Data collection was performed retrospectively by a chart review, including patient files and medical records. A total of 64 patients (female = 60.9%) treated with ECT within the period of February 2019 to March 2020 were included. Of these, 35 (54.7%) received thiopental for ECT narcosis and 29 (45.3%) were treated with propofol. Six hundred sixteen ECT treatments (mean number per case, 9.6) were performed in total. The mean electroencephalogram seizure duration (38.3 vs 28.1 seconds, t = 3.534, degrees of freedom [ df ] = 62, P < 0.001) and motor seizure duration (21.5 vs 12.0, t = 4.336, df = 62, P < 0.001) as well as postictal suppression index and heart rate increase were significantly higher in the thiopental group. Mean stimulation energy needed per session was higher in the propofol group (88.6% vs 73.0%, Mann-Whitney U test, P = 0.042). The ECT series was more likely to be interrupted due to cognitive adverse effects in the thiopental group ( P = 0.001, Pearson χ 2 = 10.514, df = 1). Number of patients achieving remission was significantly higher in the thiopental group (31.4% vs 6.9%, P = 0.015, χ 2 = 5.897, df = 1). Thiopental led to better seizure duration and quality and was associated with a higher rate of remission. As a downside, thiopental was also associated with a greater risk of cognitive adverse effects.

Relationship Between Anesthesia Depth and Quality of Seizures in Patients Undergoing Electroconvulsive Therapy: A Prospective Observational Study.

Electroconvulsive therapy under general anesthesia is an established treatment for mood disorders, such as therapy-resistant depression. As most anesthetic drugs used for induction of anesthesia increase the seizure threshold, adequate depth of anesthesia without diminishing the therapeutic efficacy of interventions is crucial. The aim of this study was to investigate whether anesthesia depth as assessed by Narcotrend (NCT) monitoring correlates with maximum seizure quality. An observational study was performed in psychiatric patients undergoing multiple interventions of electroconvulsive therapy. Seizure quality of each attendance was assessed evaluating electroencephalogram end point, electromyogram end point, postictal suppression index, the midictal amplitude, and a 3-step overall graduation. Narcotrend was used to assess anesthesia depth according to index-based electroencephalogram findings. Measurements were obtained before induction of anesthesia, before stimulation, and after arousal. Data were analyzed by means of linear mixed models and generalized estimating equations models. A total of 105 interventions in 12 patients were analyzed. Anesthesia depth before stimulation was significantly associated with seizure quality (standardized β = 0.244, P = 0.010), maximum sustained coherence (β = 0.207, P = 0.022), and electroencephalogram duration (β = 0.215, P = 0.012). A cutoff value of 41 or greater versus 40 or less for the NCT index was found appropriate to differentiate between good and less satisfactory overall seizure quality. Anesthesia depth index assessed by NCT monitoring was positively associated with seizure quality. Narcotrend monitoring may be useful in assessment of optimal anesthesia depth before stimulation.

Sevoflurane in electroconvulsive therapy: A systematic review and meta-analysis of randomised trials

Sevoflurane is the most commonly used inhaled anaesthetic in electroconvulsive therapy (ECT). The objective of this study was to provide an up-to-date and comprehensive review on how the use of sevoflurane affects seizure adequacy (seizure duration and postictal suppression index [PSI]) and circulatory dynamics in ECT. We performed a meta-analysis of RCTs that investigated seizure adequacy and circulatory dynamics in patients treated with ECT using sevoflurane (sevoflurane group) and intravenous anaesthetics (non-sevoflurane group). A total of 12 RCTs (377 patients and 1339 ECT sessions) were included. Sevoflurane significantly decreased the electroencephalogram (EEG) seizure durations in comparison with intravenous anaesthetics, whereas no significant difference was observed in PSI (EEG: 9 studies, standardized mean difference (SMD) = 0.74, 95% confidence interval (CI) = −1.11 to −0.38, p = 0.0002; PSI: 4 studies, SMD = −0.06, CI −0.13 to 0.25, p = 0.59). The use of sevoflurane in ECT significantly increased heart rate (HR) compared with intravenous anaesthetics (9 studies, SMD = 0.31, CI 012–0.51, p = 0.004). In the pre-planned subgroup analysis, sevoflurane significantly reduced seizure duration compared with other types of anaesthetics, including propofol, barbiturates and ketamine. Furthermore, it was found that the risk of adverse events in ECT with sevoflurane were not significantly different from intravenous anaesthetics (6 studies, risk ratio = 1.33, CI 0.95–1.86, p = 0.09), with agitaion being the most common adverse effects. The results of our study suggest that using sevoflurane for ECT significantly reduces seizure duration, increases maximum HR and brings about no difference in the adverse event risk compared with those using intravenous anaesthetics for ECT. Therefore, there may not be compelling evidence favouring sevoflurane use for ECT, except in cases where intravenous access is difficult.

Overlooking the obvious? Influence of electrolyte concentrations on seizure quality parameters in electroconvulsive therapy.

Clinical response to electroconvulsive therapy (ECT) depends on eliciting a generalized seizure. Though there are multiple ictal and other parameters to assess seizure quality, factors that influence these parameters have only been identified to a limited extend in antecedent studies (e.g., stimulus dosage, age). In the context of ECT, electrolyte concentrations have hardly been investigated so far-although hyponatremia is one well-known clinical factor to increase the risk of spontaneous seizures. In 31 patients with unipolar or bipolar depressive disorder, blood concentrations of sodium (Na), potassium (K), and calcium (Ca) were measured immediately prior to repeated sessions of maintenance ECT. Generalized linear mixed models were used to analyze the influence of Na, K, and Ca on seven seizure quality parameters: postictal suppression index (PSI), maximum sustained coherence (MSC), midictal amplitude, average seizure energy index, seizure duration (EEG/motor), and peak heart rate. Results show a statistically significant relationship between the serum sodium level and MSC: in the model, a reduction of 1mmol/l led to an increase in interhemispheric coherence of 0.678%. The further markers remained unaffected by changes in electrolyte concentrations. This finding provides first evidence that a lower blood concentration of sodium could enhance the quality of ECT-induced seizures in terms of higher interhemispheric coherence.

Seizure Adequacy Markers and the Prediction of Electroconvulsive Therapy Response.

Electroconvulsive therapy (ECT) is the most effective therapy for patients with treatment-resistant depression; however, some patients do not respond or relapse in a short time. Electroconvulsive therapy stimulus parameters may be related to the outcome. We carried out a retrospective study review to investigate various ECT parameters in relation to the outcome, clinical variables, and pharmacological treatments. Our aim was to understand which factors could be considered putative seizure quality markers and which are relevant to clinical practice. Two physicians evaluated the seizure length, the postictal suppression index, the wave amplitude, tachycardia, and hemispheric brain wave synchronicity in a double-blind manner for 45 treatment-resistant depression patients receiving ECT. The analysis showed a significant association between the outcome and the ECT seizure quality measured by the parameters (P = 9.9 × 10). Among patients with poor-quality seizures, 61.5% relapsed after approximately 1 month from the last ECT session. Particularly, there was an association between higher symptomatology decrease and higher quality of hemispheric brain wave synchronicity (P = 5.0 × 10), as well as a higher wave amplitude (P = 0.01). Our results confirm that ECT seizure quality was strongly correlated with the decrease of depressive symptomatology.

First experience of electroconvulsive therapy in Belarus

Electroconvulsive therapy (ECT) – a method of psychiatric and neurological treatment in which a large epileptiform seizure caused by passing an electric current through the brain of the patient in order to achieve a therapeutic effect. Clinical research of efficiency of application ECT with anesthesia, muscle relaxation and hardware analysis of EEG in patients with resistant forms of mental and behavioral disorders was held in the Republic of Belarus. The duration of the course of ECT, the frequency of sessions, as well as the method of applying electrodes for stimulation were determined by the doctor conducting the sessions of ECT. Sessions were conducted with general anesthesia with the use of muscle relaxants. Analysis of EEG data (Average Seizure Energy Index [ASEI]; Postictal Suppression Index [PSI]; COH–Maximum Sustained Coherence), on the basis of which the dose of stimulation was corrected, was conducted to assess the duration and quality of convulsive seizure during ECT. Significant clinical improvement in patients who underwent ECT sessions was achieved as a result of the study. Application of the method allowed to achieve persistent clinical remission in a short time. The clinical study showed that the use of ECT with anesthesia, muscle relaxation and hardware analysis of the EEG in the Republic of Belarus may be effective against drug-resistant forms of mental and behavioral disorders.

Sevoflurane versus propofol for electroconvulsive therapy: effects on seizure parameters, anesthesia recovery, and the bispectral index.

In this prospective randomized cross-over study we compare the effects of sevoflurane versus propofol for electroconvulsive therapy (ECT) anesthesia. Twenty four patients (ASA I-III, 18-65 years old) receiving ECT three times per week were included. Anesthesia was induced with either propofol (0.75 mg/kg iv) or 5% sevoflurane in 100% oxygen. Consecutive ECT sessions followed a 2 × 2 crossover design and a 2-day washout period until the 10th ECT. Intravenous succinylcholine (1 mg/kg) was administered while bispectral index (BIS) values were ≤60%. Electromyogram and electroencephalogram seizure duration, postictal suppression index, BIS values, mean arterial blood pressure (MAP), heart rate, times to start of spontaneous respiration, eye opening, understanding verbal commands, and side effects were compared. No differences were found between the regimens for seizure activity and recovery. At the end of ECT, MAP was higher with sevoflurane. Although BIS values were higher after sevoflurane, no differences between the regimens were found in terms of the need of muscle relaxants and in hypnosis levels. Sevoflurane (5%) may be an effective alternative to propofol for induction of anesthesia for ECT.

Sevoflurane/remifentanil versus propofol/remifentanil for electroconvulsive therapy: Comparison of seizure duration and haemodynamic responses

To compare the anaesthetic and convulsive effects of sevoflurane/remifentanil versus propofol/remifentanil combination in electroconvulsive therapy (ECT). In this prospective, randomized double-blind study, patients diagnosed with treatment-resistant depression were included for ECT. Prior to treatment, 1 µg/kg remifentanil was intravenously administered to all patients, followed by anaesthetic induction with either 0.5 mg/kg propofol or 8% sevoflurane. Following muscular paralysis with succinylcholine and hypnosis, bitemporal ECT was applied. Vital signs, depth of sedation, recovery parameters, motor and electroencephalography (EEG) convulsion activity and postictal suppression index scores were recorded. A total of 120 sessions of ECT were administered to 12 patients. Heart rate was higher in the sevoflurane group than the propofol group. Compared with the sevoflurane group, bispectral index level was lower in the propofol group during the induction period and higher during the recovery period. Anaesthetic induction and recovery times were lower, and average motor and EEG convulsion activity was longer, in the propofol group than in the sevoflurane group. Propofol/remifentanil is more successful compared with sevoflurane/remifentanil in anaesthesia management during ECT since it provides quick induction and recovery, longer seizure activity and stable haemodynamics.

Burst Suppression

A valid marker to predict seizure adequacy in electroconvulsive therapy (ECT) is still missing. Postictal suppression has been claimed to correlate with the antidepressive effectiveness of an induced seizure. Postictal suppression index (PSI) is derived from a short time span of electroencephalographic recording at seizure termination, and, alternatively, burst suppression (BS) index is defined as the percentage of suppressed epochs within a predefined time period. In a retrospective study including 9 patients with a total of 104 recorded ECT sessions, we compared the influence of variables that are known to alter seizure adequacy like age, stimulation dose, electrode position, and the number of the consecutive ECT sessions on both indices, PSI versus BS index. For PSI, electrode positioning turned out to be a significant independent variable, with bilateral placement revealing higher PSI. Electroconvulsive therapy session number was significant for BS index, with lower burst suppression in higher ECT session number. In contrast to PSI, BS index turned out to be a significant covariate of seizure duration. Postictal suppression index and BS index did not show linear but a significant rank correlation. We report first data about postictal BS index in ECT. As a measure of postictal electrical suppression, BS index appears as robust as PSI. Burst suppression index decreases during an individual ECT course, which presumably reflects the anticonvulsive effect of ECT. Less artifact-prone methods of automatic quantification of electrical suppression could improve precise determination of individual seizure adequacy.

Sevoflurane Alone and Propofol with or without Remifentanil for Electroconvulsive Therapy—a Randomised, Crossover Study

We compared the effectiveness of three anaesthetic regimens (propofol alone, propofol with remifentanil and sevoflurane alone), with respect to seizure duration and seizure quality in patients undergoing electroconvulsive therapy. Thirty-nine patients underwent a total of 234 electroconvulsive therapy treatments in this prospective, observer blinded, crossover study. Each patient received either propofol 1 mg/kg alone (Group P), propofol 0.5 mg/kg and remifentanil 1 µg/kg (Group R), or sevoflurane alone 6% (Group S) for their initial electroconvulsive therapy session. The patients subsequently received an alternative regimen in their next session, such as from propofol 1 mg/kg alone to propofol 0.5 mg/kg and remifentanil 1 µg/kg, from propofol 0.5 mg/kg and remifentanil 1 µg/kg to sevoflurane alone 6%, or from sevoflurane alone 6% to a continuing alternation between drugs at each session, until their sixth session. Muscle paralysis was achieved with 1 mg/kg succinylcholine. Seizure duration, postictal suppression index, early and midictal amplitude were recorded. The mean motor and electroencephalogram seizure durations were significantly longer in Groups P and R compared to Group S (P <0.001). The postictal suppression index and early and midictal amplitude values were not significantly different among the groups. These findings indicate that the three anaesthetic regimens had similar effects on seizure quality parameters, although sevoflurane was associated with shorter seizure durations than propofol or propofol-remifentanil.

Ketofol (Mixture of Ketamine and Propofol) Administration in Electroconvulsive Therapy

The aim of this study was to evaluate the effect of a ketamine:propofol combination ('ketofol') for electroconvulsive therapy on seizure activity, haemodynamic response and recovery parameters, and to compare with these with the effects of propofol alone. Twenty-four patients underwent a total of 144 electroconvulsive therapy sessions, allocated in this prospective, double-blind, crossover study. Patients were randomly assigned to receive 1 mg/kg ketofol (0.5 mg/kg propofol plus 0.5 mg/kg ketamine) or 1 mg/kg propofol 1% for anaesthesia induction. Seizure duration and quality, haemodynamic data, recovery parameters and side-effects were recorded and analysed between groups. Both motor and electroencephalography seizure durations in the ketofol group (29 ± 17 and 41 ± 17 seconds, respectively) were similar to that in the propofol group (28 ± 13 and 38 ± 16 seconds, respectively). Postictal suppression index was higher in the ketofol group (89.63 ± 7.88) than in the propofol group (79.74 ± 14.6) (P <0.05). In the ketofol group, heart rate after the seizure ended and mean arterial pressures, recorded at 0 and 5 minutes after the seizure ended, were higher than in the propofol group. Time to obeying commands was longer in the ketofol group (P <0.05). There were no untoward psychological reactions following ketofol. Although no superiority to propofol in terms of seizure duration, haemodynamic or recovery parameters was found, the ketofol mixture selected in our study provided better seizure quality than propofol. We conclude that ketofol can be an alternative strategy to enhance the seizure quality and clinical efficiency of electroconvulsive therapy.

The Effect of Repeated Etomidate Anesthesia on Adrenocortical Function During a Course of Electroconvulsive Therapy

Etomidate may affect adrenocortical function. We conducted an investigation of the comparative effects of etomidate and propofol during electroconvulsive therapy (ECT) on adrenocortical function and hemodynamics. Patients in group T received etomidate and those in group B received propofol during intravenous anesthesia in ECT. Patients underwent ECT once every 2 days for 6 times. The serum levels of cortisol (Cor) and adrenocorticotropic hormone were determined 5 minutes before first anesthesia (baseline level, D0), and 24 hours (D1) as well as 48 hours after the last ECT (D2). At the same time, the hemodynamics was measured 2 minutes before anesthetic induction (T0), 30 seconds (T1) and 20 minutes after ECT (T2). Electrographic seizure duration (t), average seizure energy index, and postictal suppression index were recorded. Compared with the baseline level, serum Cor levels in group T were markedly decreased, but in normal ranges, at 24 hours after second and sixth treatments. No significant difference in serum Cor level was observed between the baseline and 48 hours posttreatment. In group B, there was no significant difference in serum Cor level between the baseline and 24 hours as well as 48 hours after each treatment. Furthermore, no significant difference in adrenocorticotropic hormone level was observed between the baseline and 24 hours as well as 48 hours posttreatment. However, the hemodynamics markedly changed during ECT and reached the preanesthetic level at 20 minutes posttreatment. The ECT-induced seizure duration in group T was longer than that in group B. However, seizure energy index and postictal suppression index was not significantly different between groups T and B. Etomidate and propofol would not affect the adrenocortical function during ECT, and hemodynamics reached normal level in a short time after ECT. Etomidate and propofol were both safe intravenous anesthetics during ECT, although etomidate was associated with comparatively longer seizure duration.

Remifentanil

The primary objectives were to review studies that used remifentanil in electroconvulsive therapy (ECT) and to determine whether remifentanil has potential advantages over other anesthetics. The author reviewed 12 original studies obtained through a MEDLINE database search that examined remifentanil as an anesthetic in patients receiving ECT. Remifentanil was associated with longer seizure durations when used as the sole anesthetic or as an adjunct when the primary anesthetic dose was lowered. Individual studies reported higher postictal suppression index and lower initial seizure thresholds and less rise in seizure thresholds with remifentanil. Data on hemodynamic effects were mixed but suggested favorable effects with remifentanil when seizure duration was not prolonged. Studies support the use of remifentanil in ECT, particularly in patients with brief seizures, high seizure thresholds, and postictal hemodynamic instability. Broad variability in study design, selection and dosing of anesthetics, electrode placement, and limited examination of potentially relevant variables such as age, sex, concomitant medications; and stimulus parameters attenuate the certainty of these results. Advantages in safety and efficacy over other anesthetics remain undetermined. Further study of remifentanil in ECT is warranted, given the methodological limitations and exclusion of important outcomes in the current literature.

Comparison of Enflurane and Propofol in Electroconvulsive Therapy, a Randomized Crossover Open Preliminary Study on Seizure Duration and Anaesthetic Recovery

Electroconvulsive therapy (ECT) is commonly used for treatment of depression, mania and affective disorders. Anaesthetics for general anaesthesia during ECT should have rapid onset, rapid emerge, not interfere with seizure activity and not shorten seizure duration. The aim of this study is to compare effects of enflurane, a pro-convulsive anaesthetic agent, and propofol on seizure durations, postictal suppression index and recovery times during electroconvulsive therapy. Unpremedicated subjects were divided into two groups according to induction of anaesthesia. Patients were induced for ECT with 5% enflurane in group E and 1.2mg.kg(-1) propofol in group P until loss of consciousness. The durations of electroencephalogram (EEG) and motor seizures, postictal suppression index, time to spontaneous breathing, duration of eye opening, and obeying commands were recorded. There was no statistically significant difference between the groups regarding motor and EEG seizure times and postictal suppression index on the EEG records. Recovery times (times of starting spontaneous breathing, eye opening, and obeying command) were significantly shorter in group E compared to group P. No nausea or vomiting were observed and no ECG abnormality was noted except transient sinus bradycardia and sinus tachycardia. Although sufficient seizure for the treatment was provided during enflurane anaesthesia, any additional benefit was not revealed regarding seizure times or postictal suppression index when compared to propofol anaesthesia. On the other hand, recovery times after enflurane anaesthesia were shorter than propofol anaesthesia. However, there is still a need for further study in different ETCO(2) levels.

P02-562 - Analysis of treatment results in the electroconvulsive therapy unit of centro hospitalar psiquiatrico de lisboa (CHPL)

IntroductionElectroconvulsive therapy is widely used for treatment-resistant psychiatric patients, with remission rates close to 50% and response rates between 60–70%. Post ictal suppression index (PISI) has been positively correlated with clinical outcome.ObjectivesCharacterize the treatment results of the electroconvulsive therapy unit of CHPL; find a correlation between improvement on HAM-D, PANSS and PSAS and PISI.MethodsThe patient data was collected and divided according to ICD-10 diagnosis. Evaluation scales were applied at the beginning and end of treatment: depressed patients (F31.3–5; F33; F20.4; F25.1) - HAM-D; schizophrenic/ schizoaffective/ bipolar-manic or mixed patients (F20.X, F25.X, F31.0, F31.6) - PANSS; with any of these diagnosis - PSAS. A correlation between the points of improvement on each scale and PISI was investigated using the Pearson product-moment correlation coefficient.ResultsOf 101 depressed patients, 33,7% showed remission and 49,5% showed response, over 11 sessions (average). The reduction on HAM-D score was significantly greater for patients with initial HAM-D score &gt; 18 versus HAM-D ≤ 18 (52,9% versus 37,75%). Patients with unipolar depression (N = 72) and bipolar depression (N = 22) showed comparable results (response:47,2% versus 52,4%; remission: 30,6% versus 40,1%). Schizophrenic patients (N = 43) had higher response rates: 88%. No correlation was found between PISI and HAM-D, PANSS or PSAS improvement (r = -0,1;-0,01;-0,07).ConclusionResponse and remission rates in depressed patients were inferior to other ECT studies, except in patients with higher severity. Those rates were comparable for schizophrenic patients. PISI did not correlate with clinical outcome.

Ictal physiological characteristics of remitters during bilateral electroconvulsive therapy

Ictal heart rate (HR) and postictal suppression in ictal EEG are believed to be predictive of the therapeutic efficacy of eletroconvulsive therapy (ECT) for depression. However, regarding ictal peak HR, previous studies investigated ictal HR on only one or two occasions during the course of ECT. We prospectively examined whether two physiological parameters, ictal peak HR and postictal suppression in ictal EEG, during every session, including those with abortive seizure, predicted ECT efficacy. Ictal peak HR and postictal suppression index were analyzed in 53 consecutive inpatients with depression using generalized estimating equations analysis, which corrects for the repeated nature of the observations. The peak HR and postictal suppression index were associated with therapeutic efficacy in remitters during sessions with adequate seizure. The physiological characteristics of the remitters included lower peak HR, lower stimulus energy, and higher postictal suppression index. However, these results could not be generalized, and are limited to non-atropine conditions and bilateral ECT.

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.