Right Unilateral Electroconvulsive Therapy Research Articles

Clinical Outcomes of Magnetic Seizure Therapy vs Electroconvulsive Therapy for Major Depressive Episode

Electroconvulsive therapy (ECT) is highly effective and rapid in treating depression, but it carries a risk of significant cognitive adverse effects. Magnetic seizure therapy (MST), an investigational antidepressant treatment, may maintain the robust antidepressant efficacy of ECT while substantially reducing adverse effects due to its enhanced focality and weaker stimulation strength; however, previous clinical trials of MST were limited by small sample sizes. To compare the antidepressant efficacy of MST vs ultrabrief pulse right unilateral (RUL) ECT. A between-participants, double-blinded, randomized clinical trial was conducted at 3 academic hospitals from June 2007 to August 2012. Adults aged 18 to 90 years who were referred for treatment with ECT, had a major depressive episode in the context of major depressive disorder or bipolar disorder, and had a baseline 24-item Hamilton Depression Rating Scale (HDRS-24) total score of 18 or higher were included. Participants were randomly assigned 1:1 to treatment with MST or ultrabrief pulse RUL ECT. After the treatment course, patients were naturalistically followed up for up to 6 months to examine the durability of clinical effects. Treatment with MST, applied at 100 Hz at 100% of the maximum device power for 10 seconds, or ultrabrief pulse RUL ECT, applied at 6 times seizure threshold. The primary outcome was change from baseline in HDRS-24 total score, with patients followed up for up to 6 months. A reduction of at least 50% in the HDRS-24 score indicated response, and at least a 60% decrease in the HDRS-24 score and a total score of 8 or less indicated remission. Of the 73 participants (41 [56.2%] female; mean [SD] age, 48 [14.1] years), 35 were randomized to MST and 38 to ECT. Among them, 53 (72.6%) were classified as completers (29 in the MST group and 24 in the ECT group). Both MST and ECT demonstrated clinically meaningful antidepressant effects. In the intent-to-treat sample, 18 participants (51.4%) in the MST group and 16 (42.1%) in the ECT group met response criteria; 13 (37.1%) in the MST group and 10 (26.3%) in the ECT group met remission criteria. Among completers, 17 of 29 (58.6%) in the MST group and 15 of 24 (62.5%) in the ECT group met response criteria; 13 of 29 (44.8%) in the MST group and 10 of 24 (41.7%) in the ECT group met remission criteria. There was no significant difference between MST and ECT for either response or remission rates. However, the mean (SD) number of treatments needed to achieve remission was 9.0 (3.1) with MST and 6.7 (3.3) with ECT, a difference of 2.3 treatments (t71.0 = 3.1; P = .003). Both MST and ECT showed a sustained benefit over a 6-month follow-up period, again with no significant difference between them. Compared with MST, ECT had significantly longer time to orientation after treatment (threshold level: F1,56 = 10.0; P = .003) and greater severity of subjective adverse effects, particularly in the physical and cognitive domains. This randomized clinical trial found that the efficacy of MST was indistinguishable from that of ultrabrief pulse RUL ECT, the safest form of ECT currently available. These results support the continued development of MST and provide evidence for advantages relative to state-of-the-art ECT. ClinicalTrials.gov Identifier: NCT00488748.

Brain volumetric correlates of electroconvulsive therapy versus transcranial magnetic stimulation for treatment-resistant depression

BackgroundElectroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS) are effective neuromodulation therapies for treatment-resistant depression (TRD). While ECT is generally considered the most effective antidepressant, rTMS is less invasive, better tolerated and leads to more durable therapeutic benefits. Both interventions are established device antidepressants, but it remains unknown if they share a common mechanism of action. Here we aimed to compare the brain volumetric changes in patients with TRD after right unilateral (RUL) ECT versus left dorsolateral prefrontal cortex (lDLPFC) rTMS. MethodsWe assessed 32 patients with TRD before the first treatment session and after treatment completion using structural magnetic resonance imaging. Fifteen patients were treated with RUL ECT and seventeen patients received lDLPFC rTMS. ResultsPatients receiving RUL ECT, in comparison with patients treated with lDLPFC rTMS, showed a greater volumetric increase in the right striatum, pallidum, medial temporal lobe, anterior insular cortex, anterior midbrain, and subgenual anterior cingulate cortex. However, ECT- or rTMS-induced brain volumetric changes were not associated with the clinical improvement. LimitationsWe evaluated a modest sample size with concurrent pharmacological treatment and without neuromodulation therapies randomization. ConclusionsOur findings suggest that despite comparable clinical outcomes, only RUL ECT is associated with structural change, while rTMS is not. We hypothesize that structural neuroplasticity and/or neuroinflammation may explain the larger structural changes observed after ECT, whereas neurophysiological plasticity may underlie the rTMS effects. More broadly, our results support the notion that there are multiple therapeutic strategies to move patients from depression to euthymia.

Ultrabrief Right Unilateral Electroconvulsive Therapy for the Treatment of the Neuropsychiatric Symptoms of Dementia with Lewy Bodies.

Dementia with Lewy bodies (DLB) is a debilitating disorder associated with a number of distressing neuropsychiatric symptoms. There is currently limited guidance regarding the most effective strategies of managing these symptoms, and both pharmacologic and nonpharmacologic strategies are often used. Electroconvulsive therapy (ECT) has been reported as a potential nonpharmacologic method to alleviate some of these debilitating neuropsychiatric symptoms. However, there remains a paucity of evidence in current literature. This report aims to add to existing literature regarding ECT in DLB by highlighting successful treatment in seven cases. Our study is a retrospective case series of 7 patients with DLB who received treatment with ultrabrief (UB) right unilateral (RUL) ECT for the treatment of agitation and depressive symptoms. Participants included patients with a diagnosis of DLB who were admitted to Emory University Hospital at Wesley Woods from 2011 to 2020 presenting with agitation and/or depressive symptoms after failing pharmacologic intervention. Patients underwent UB RUL ECT administered by a board-certified psychiatrist. After treatment, Pittsburg Agitation Scale and Clinical Global Impression-Improvement scales were recorded as measures of agitation and clinical improvement, respectively. All 7 patients responded to UB RUL ECT with marked improvement in their presenting symptoms of agitation and/or depression without significant adverse effects from treatment. Ultrabrief RUL ECT seems to be a safe and effective treatment of the agitative and depressive features of DLB.

Effects of modifying the electrode placement and pulse width on cognitive side effects with unilateral ECT: A pilot randomised controlled study with computational modelling

BackgroundThe electrode placement and pulse width for electroconvulsive therapy (ECT) are important treatment parameters associated with ECT related retrograde memory side-effects. Modification of these parameters with right unilateral (RUL) ECT may have utility for further reducing these side-effects. ObjectiveThis study explored use of the frontoparietal (FP) placement for reducing retrograde memory side effects with ECT. We hypothesised that superior retrograde memory outcomes would occur with FP compared to temporoparietal (TP) placement and with ultrabrief (UB: 0.3 ms) compared to brief pulse (BP: 1.0 ms) width ECT. MethodsIn this randomised cross-over, double-blinded study, participants received a single treatment of BP TP, BP FP, UB TP and UB FP ECT. Neuropsychological testing was conducted prior to and immediately following each treatment. Computational modelling was conducted to explore associations between E-fields in regions-of-interest associated with memory. ResultsNine participants completed the study. The FP placement was not superior to TP for retrograde memory outcomes. For both electrode placements UB pulse width was associated with significantly better visual retrograde memory compared to BP (p < .05). With TP ECT, higher E-fields in regions-of-interest were significantly associated with greater visual retrograde memory side-effects (hippocampi: r = −0.77, p = .04; inferior frontal gyri: r = −0.92, p < .01; middle frontal gyri: r = −0.84, p = .02). ConclusionsModification of pulse-width had greater effects than electrode placement for reducing retrograde memory side-effects with RUL ECT. Preliminary findings suggested that higher E-fields may be associated with greater cognitive side-effects with ECT.

432 - Ultrabrief Right Unilateral ECT in Older Adults with Catatonia: A Case Series and Literature Review

Objectives:Comparing Ultra-brief (UB) Right Unilateral Electroconvulsive Therapy (RU ECT) to the existing literature, this case series highlights the use of the treatment with geriatric patients.Methods:This is a retrospective chart review of 5 patients with catatonia who were successfully treated with UB RUL ECT. Medical records were reviewed for clinical data and ECT treatment. The existing literature is compared and contrasted with other published cases. Quick Inventory of Depressive Symptomatology (QIDS) was completed both pre-ECT and post-ECT. Clinical Global Impression–Improvement (CGI-I) scale was performed post-ECT. Response was defined as decrease of QIDS by 50% and remission was defined as QIDS ≤5. CGI response was defined as CGI-I ≤2.Results:All patients received UB RUL ECT treatment (mean age 67, 100% female). 20% (n=2) were caucasian. 60% had mood disorders and 40% had psychotic disorders. Number of treatments in the acute treatment course ranged from 5 to 20, charge was dosed at 6-10 times the seizure threshold determined at first treatment. All patients had a significant clinical response to ECT as reflected by clinical data, ECT procedure notes, and rating scales when available. All patients completed post ECT CGI-I. Response rate was 60% (n = 3). We also assessed QIDS scores for patients with comorbid depression. Out of these patients, 40% (n = 2) were unable to complete baseline QIDS secondary to symptoms severity. Mean baseline QIDS for the remaining patients was 9.67 (SD 1.53). Post-treatment QIDS was 3.67 (SD 5.51). Paired-samples t-test comparing these scores at baseline and post-ECT demonstrated a significance P value of 0.14. None of the patients experienced worsening of cognitive function.Conclusions:UB RUL ECT is a safe and effective treatment for Catatonia. Our data demonstrate clinical improvement in patients with Catatonia with UB RUL ECT. In addition, this method may lower the burden of cognitive effects that can significantly benefit the older adult population. The literature is limited regarding the use of Ultra-brief (&lt;0.37 milisec) Right Unilateral (RU) ECT in Catatonia. Additional studies will benefit from the inclusion of objective metrics such as Bush Francis Catatonia Scale, Scale for the Assessment of Psychotic Symptoms (SAPS), and the systematic evaluation of cognitive status and function.

Right Unilateral Versus Bilateral Electroconvulsive Therapy in Patients With Clinical Depression

IntroductionElectroconvulsive therapy (ECT) is a functional treatment for a significant mental illness that involves a momentary application of electrical stimulation to induce generalized seizures. The use of right unilateral (RUL) and bilateral (BL) ECT has been controversial. Thus, the study aimed at comparing the effectiveness of RUL ECT and BL ECT in treating depression.MethodologyA longitudinal study was conducted between September 2016 and January 2021 at a tertiary care hospital in Sindh, Pakistan. All patients over the age of 18 with clinically diagnosed depression in the last month were included in the study. Baseline depression scores and post-treatment scores were determined using Hamilton Depression Rating Scale (HDRS). All patients were assigned to each treatment group. Group A was administered right unilateral electroconvulsive therapy, while group B was administered bilateral electroconvulsive therapy. Adverse effects were documented right after treatment, at four hours, and then one day after therapy. Depression severity was determined after each ECT session using the HDRS scale. Electroconvulsive therapy was discontinued when an HDRS score of 10 was achieved. Results The mean HDRS score at baseline in the bilateral ECT group was 24.99 ± 3.938, which lowered to 17.56 ± 2.65 by the 3rd session, 12.45 ± 3.76 by the 6th session, and to 11.86 ± 2.3 by the end of treatment (p<0.0001). Similarly, the right unilateral ECT was equally effective in improving the depressive symptoms (p<0.0001). There was no significant difference between the efficacy of bilateral and unilateral placements of electrodes in electroconvulsive therapy (p=0.116).

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

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.

Right unilateral versus bilateral formula-based electroconvulsive therapy in the treatment of major depression in elderly patients: a randomised, open label, pilot controlled trial.

Electroconvulsive therapy (ECT) remains the most effective treatment of depression in the elderly population; however, it is still unclear which type of ECT is most beneficial in this population. The aims of this study were: (i) to assess the feasibility of a randomised controlled trial in elderly depressed patients treated with right unilateral (RUL) or fronto-temporal bilateral (BT) formula-based ECT; (ii) to compare formula-based RUL and BT ECT in terms of efficacy, safety and tolerability in this population. The study lasted 3 years and managed to randomise 29 patients over 65 years old to receive either BT (n = 14) or RUL (n = 15) ECT. Brief pulse width (0.5 ms) and age-based dosing method were applied. The clinical efficacy was assessed using Hamilton Depression Rating Scale, somatic state was monitored throughout the ECT course. In neuropsychological examination general cognitive performance, executive functions, verbal fluency, memory, autobiographical memory were evaluated. The recruitment was poor due to small number of patients able to give informed consent. ECT proved to be a highly effective and safe method of treatment among elders. Formula-based RUL ECT did not differ from BT in antidepressant efficacy and had cognitive advantages - the indices of general cognitive performance, verbal fluency and memory were significantly better than before the treatment in the RUL group. Decline in retrieval consistency of autobiographical memory was more pronounced in the BT group, although it was observed across both groups. Formula-based RUL ECT might not differ from BT in antidepressant efficacy and has an advantage in terms of tolerability.

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.

ECT non­remitters: prognosis and treatment after 12 unilateral electroconvulsive therapy sessions for major depression

BackgroundDepressive disorder causes significant suffering in patients and caregivers worldwide. Electroconvulsive therapy (ECT) is a highly effective antidepressant treatment, but little is known about the prognosis and treatment of patients who do not achieve remission with ECT. We investigated prognosis and treatment of patients with major depression who did not achieve remission after 12 unilateral electroconvulsive therapy sessions. MethodsWe conducted a retrospective, naturalistic follow-up study. Patients who had previously participated in a double-blind randomized controlled trial that compared brief pulse with ultra-brief pulse ECT and who had not achieved remission after 12 right unilateral (RUL) ECT sessions were selected for this study. We analysed the type of treatments received during the 6-month follow-up and studied the occurrence of remission and response. The primary outcome was remission, defined as a Montgomery-Åsberg Depression Rating Scale score <10. ResultsEighty-one patients were randomized, of which 18 patients did not remit. Eight of these non-remitters achieved remission during follow-up (44.4%) while 7 did not achieve remission (38.9%). Remission data could not be retrieved for 3 patients (16.7%). Remission was achieved in 6 patients by a combination of continuing unilateral ECT with antidepressants or switching to bilateral ECT. LimitationsThis is a retrospective study with only a small number of patients. Treatment after RUL ECT non-remission was not standardized. ConclusionWhen patients with major depression do not achieve remission after 12 RUL ECT sessions, they have still a reasonable chance of remission within 6 months. Continuing ECT has the best chance of success.

Computational comparison of conventional and novel electroconvulsive therapy electrode placements for the treatment of depression

BackgroundElectroconvulsive therapy (ECT) is a highly effective treatment for severe psychiatric disorders. Despite its high efficacy, the use of ECT would be greater if the risk of cognitive side effects were reduced. Over the last 20 years, developments in ECT technique, including improvements in the dosing methodology and modification of the stimulus waveform, have allowed for improved treatment methods with reduced adverse cognitive effects. There is increasing evidence that the electrode placement is important for orienting the electrical stimulus and therefore modifying treatment outcomes, with potential for further improvement of the placements currently used in ECT. ObjectiveWe used computational modelling to perform an in-depth examination into regional differences in brain excitation by the ECT stimulus for several lesser known and novel electrode placements, in order to investigate the potential for an electrode placement that may optimise clinical outcomes. MethodsHigh resolution finite element human head models were generated from MRI scans of three subjects. The models were used to compare regional differences in average electric field (EF) magnitude among a total of thirteen bipolar ECT electrode placements, i.e. three conventional placements as well as ten lesser known and novel placements. Results and conclusionIn this exploratory study on a systemic comparison of thirteen ECT electrode placements, the EF magnitude at regions of interest (ROIs) was highly dependent upon the position of both electrodes, especially the ROIs close to the cortical surface. Compared to conventional right-unilateral (RUL) ECT using a temporo-parietal placement, fronto-parietal and supraorbito-parietal RUL also robustly stimulated brain regions considered important for efficacy, while sparing regions related to cognitive functions, and may be a preferrable approach to the currently used placement for RUL ECT. The simulations also found that regional average EF magnitude varied between individual subjects, due to factors such as head size, and results also depended on the size of the defined ROI.

Magnitude of Reduction and Speed of Remission of Suicidality for Low Amplitude Seizure Therapy (LAP-ST) Compared to Standard Right Unilateral Electroconvulsive Therapy: A Pilot Double-Blinded Randomized Clinical Trial.

Background: Although treatment guidelines support use of electroconvulsive therapy (ECT) for acute suicidality, it is associated with cognitive side effects. The effect of Low Amplitude Seizure Therapy (LAP-ST) on suicidality is unknown. Our prior precision LAP-ST (pLAP-ST) performing titrating in the current domain has provided initial proof of concept data in humans of its advantage in terms of reduction of cognitive side effects. The aims of this report are to: 1) compare LAP-ST (at 500mA) versus standard Right Unilateral (RUL) ECT (at 900 mA) in terms of magnitude of remission of suicidality in a randomized allocation and 2) compare the speed of remission of suicidality between LAP-ST versus RUL ECT. Methods: Patients were randomized to either LAP-ST or RUL ECT. The scores pertaining to the suicidal ideation (SI) item on the Montgomery-Åsberg Depression Rating Scale (MADRS) were analyzed using descriptive analysis and no confirmatory statistical analysis was performed due to a priori sample size limitations for this pilot study. SI item remission was defined as 2 or below on this item. Results: Eleven patients with major depressive episode (MDE) of mainly unipolar or bipolar disorders signed consent. Of these, 7 were eligible and were randomized and included in the analysis; all were actively suicidal at baseline (suicide item above 2), except 1 patient who had suicide item at 2 in the RUL ECT group. Suicidality remitted on average by session 3 and remission occurred for all patients by session 4. The SI mean score improvement from baseline to endpoint for LAP-ST was 5.1 and for RUL ECT was 3.0. Conclusions: LAP-ST has larger effect size and speed of remission of suicidality compared to standard RUL ECT. Future studies are warranted for replicating these findings. (ClinicalTrials.gov ID: NCT02583490).

Pertinence of Titration and Age-Based Dosing Methods for Electroconvulsive Therapy: An International Retrospective Multicenter Study.

Although the dosage of electroconvulsive therapy (ECT) stimulus has a major impact on the efficacy and safety of this treatment, the method used to determine an optimal dosage remains a matter of debate. We investigated factors influencing the seizure threshold (ST) in a large-sample study and compared age-based and titration dosing methods in terms of charge. A retrospective study examined data from 503 patients across France and Canada. The patients underwent right unilateral (RUL) or bitemporal (BT) ECT during a titration session before undergoing ECT. Seizure threshold and charge differences between age-based and titration-predicted methods were derived for each RUL and BT patient and compared according to sex, age, and anesthetic agents. Based on our results, ST is a function of electrode placement, sex, age, and anesthetic agents. Titration and age-based methods led to completely different patterns of charges for the same electrode placement, especially in elderly and in women in the RUL group. Regression models showed that differences between the age-based and titration methods varied with respect to age, sex, and anesthetic agent. Specifically, significant effects of sex and age were observed for RUL ECT and of sex and anesthetics for BT ECT. This study revealed that several factors significantly influence the prediction of ECT dose, depending on individuals and treatment modalities. Caution should be exercised when using nonindividualized methods to calculate ST.

Brain Volumetric Correlates of Right Unilateral Versus Bitemporal Electroconvulsive Therapy for Treatment-Resistant Depression

The selection of a bitemporal (BT) or right unilateral (RUL) electrode placement affects the efficacy and side effects of ECT. Previous studies have not entirely described the neurobiological underpinnings of such differential effects. Recent neuroimaging research on gray matter volumes is contributing to our understanding of the mechanism of action of ECT and could clarify the differential mechanisms of BT and RUL ECT. To assess the whole-brain gray matter volumetric changes observed after treating patients with treatment-resistant depression with BT or RUL ECT, the authors used MRI to assess 24 study subjects with treatment-resistant depression (bifrontotemporal ECT, N=12; RUL ECT, N=12) at two time points (before the first ECT session and after ECT completion). Study subjects receiving BT ECT showed gray matter volume increases in the bilateral limbic system, but subjects treated with RUL ECT showed gray matter volume increases limited to the right hemisphere. The authors observed significant differences between the two groups in midtemporal and subcortical limbic structures in the left hemisphere. These findings highlight that ECT-induced gray matter volume increases may be specifically observed in the stimulated hemispheres. The authors suggest that electrode placement may relevantly contribute to the development of personalized ECT protocols.

A systematic review of left unilateral electroconvulsive therapy.

To systematically review the published clinical trials, case series, and case reports on left unilateral (LUL) electrode placement for clinical electroconvulsive therapy (ECT). PubMed, Ovid Medline, and the Cochrane Library were searched for articles concerning LUL ECT. Number of patients, efficacy, and cognitive outcomes were extracted from the papers that met our inclusion criteria. A total of 52 articles were included in this review, consisting of 33 clinical trials, seven case series, and 12 case reports. Overall, the efficacy of LUL electrode placement for the treatment of depression and psychosis is similar to that of right unilateral (RUL) and bilateral (BL) electrode placements. Patients receiving LUL ECT tend to experience more verbal memory impairment than patients receiving RUL ECT, but less verbal impairment than patients receiving BL ECT. In contrast, patients receiving LUL ECT tended to experience the least visual and nonverbal memory impairment, compared to patients receiving RUL or BL ECT.

Minimum Electric Field Exposure for Seizure Induction with Electroconvulsive Therapy and Magnetic Seizure Therapy.

Lowering and individualizing the current amplitude in electroconvulsive therapy (ECT) has been proposed as a means to produce stimulation closer to the neural activation threshold and more focal seizure induction, which could potentially reduce cognitive side effects. However, the effect of current amplitude on the electric field (E-field) in the brain has not been previously linked to the current amplitude threshold for seizure induction. We coupled MRI-based E-field models with amplitude titrations of motor threshold (MT) and seizure threshold (ST) in four nonhuman primates (NHPs) to determine the strength, distribution, and focality of stimulation in the brain for four ECT electrode configurations (bilateral, bifrontal, right-unilateral, and frontomedial) and magnetic seizure therapy (MST) with cap coil on vertex. At the amplitude-titrated ST, the stimulated brain subvolume (23-63%) was significantly less than for conventional ECT with high, fixed current (94-99%). The focality of amplitude-titrated right-unilateral ECT (25%) was comparable to cap coil MST (23%), demonstrating that ECT with a low current amplitude and focal electrode placement can induce seizures with E-field as focal as MST, although these electrode and coil configurations affect differently specific brain regions. Individualizing the current amplitude reduced interindividual variation in the stimulation focality by 40-53% for ECT and 26% for MST, supporting amplitude individualization as a means of dosing especially for ECT. There was an overall significant correlation between the measured amplitude-titrated ST and the prediction of the E-field models, supporting a potential role of these models in dosing of ECT and MST. These findings may guide the development of seizure therapy dosing paradigms with improved risk/benefit ratio.

Cognitive Effects of Bifrontal Versus Right Unilateral Electroconvulsive Therapy in the Treatment of Major Depression in Elderly Patients: A Randomized, Controlled Trial.

Bifrontal (BF) electrode placement has been explored to refine the electroconvulsive therapy (ECT) technique. No previous study has compared the cognitive effects of BF versus right unilateral (RUL) ECT by only including the subgroup that is most likely to receive it: elderly patients with major depression. Nondemented patients (n = 65) with major depression, aged 60 to 85 years, were randomly allocated to BF ECT and RUL formula-based ECT. Cognitive function was assessed at baseline (T1), within 1 week after a course of ECT (T2), and 3 months after T2 (T3). Six neuropsychological test measures of memory, 5 of executive function, and 3 of information-processing speed were administered. According to linear mixed models, there were no significant differences between the BF and RUL groups at any time. The retrograde memory score for public facts declined more for the RUL group (P < 0.001) than the BF group (P = 0.005) from baseline to the first retest and remained stable for both groups from T2 to T3. A rapid improvement in selective attention was observed in the RUL group from T1 to T2, but the scores remained stable from T2 to T3 (P < 0.001). This measure remained stable in the BF group from T1 to T3. Our findings indicate that there were negligible differences in the cognitive effects of formula-based BF or RUL ECT. The overall cognitive effects of ECT were equally favorable for each of the groups.

Electroconvulsive therapy: Brief versus ultrabrief pulse right unilateral electroconvulsive therapy

IntroductionElectroconvulsive therapy (ECT) is an effective depression treatment, but it has potential cognitive side effects. Bitemporal ECT has been traditionally used, but in recent decades, right unilateral (RUL) electrode placement has been proposed to decrease the cognitive side effects of ECT. Ultrabrief pulse (UBP) right unilateral (RUL) ECT is an increasingly used treatment option that can potentially combine efficacy with lesser cognitive side effects.ObjectivesTo evaluate whether ultrabrief pulse (UBP) right unilateral (RUL) electroconvulsive therapy (ECT) is as effective as brief pulse (BP) RUL ECT in addition to cause lesser cognitive side effects.Material and methodsA search is performed in the available scientific literature on systematic review and meta-analysis of the subject under study, through the database PubMed.Results– Current evidence supports the efficacy of right unilateral (RUL) electroconvulsive therapy (ECT) given with an ultrabrief pulse width in the treatment of depression;– ultrabrief pulse RUL ECT leads to lesser cognitive side effects than traditional forms of ECT;– ultrabrief pulse RUL ECT may be slightly less effective than traditional forms of ECT.ConclusionsBP compared with UBP RUL ECT was slightly more efficacious in treating depression and required fewer treatment sessions, but led to greater cognitive side effects. The decision of whether to use BP or UBP RUL ECT should be made on an individual patient basis and should be based on a careful weighing of the relative priorities of efficacy versus minimization of cognitive impairment.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Modulation of Intrinsic Brain Activity by Electroconvulsive Therapy in Major Depression

One of the most effective interventions for intractable major depressive episodes is electroconvulsive therapy (ECT). Because ECT is also relatively fast-acting, longitudinal study of its neurobiological effects offers critical insight into the mechanisms underlying depression and antidepressant response. Here we assessed modulation of intrinsic brain activity in corticolimbic networks associated with ECT and clinical response. We measured resting-state functional connectivity (RSFC) in patients with treatment-resistant depression (n=30), using functional magnetic resonance imaging (fMRI) acquired before and after completing a treatment series with right-unilateral ECT. Using independent component analysis, we assessed changes in RSFC with 1) symptom improvement and 2) ECT regardless of treatment outcome in patients, with reference to healthy controls (n=33, also scanned twice). After ECT, consistent changes in RSFC within targeted depression-relevant functional networks were observed in the dorsal anterior cingulate (ACC), mediodorsal thalamus (mdTh), hippocampus, and right anterior temporal, medial parietal, and posterior cingulate cortex in all patients. In a separate analysis, changes in depressive symptoms were associated with RSFC changes in the dorsal ACC, mdTh, putamen, medial prefrontal, and lateral parietal cortex. RSFC of these regions did not change in healthy controls. Neuroplasticity underlying clinical change was in part separable from changes associated with the effects of ECT observed in all patients. However, both ECT and clinical change were associated with RSFC modulation in dorsal ACC, mdTh and hippocampus, which may indicate that these regions underlie the mechanisms of clinical outcome in ECT and may be effective targets for future neurostimulation therapies.