Unilateral Electrode Placement Research Articles

Seizure Duration and Electroconvulsive Therapy in Major Depressive Disorder

Electroconvulsive therapy (ECT), wherein a generalized epileptic seizure is induced, is a treatment for major depressive disorder (MDD). Currently, it is unclear whether there is an association between seizure length and treatment outcome. To explore the association between seizure duration, potential confounding variables, and ECT treatment outcome. This population-based cohort study obtained data from the Swedish National Quality Register for ECT. Patients treated for unipolar MDD with unilateral electrode placement between January 1, 2012, and December 31, 2019, were included. The electroencephalographic (EEG) seizure duration from the first ECT treatment session for each patient was used for analysis. Data analyses were performed between March 2021 and May 2024. The primary outcome was remission, defined as a cutoff score of less than 10 points on the self-assessment version of the Montgomery-Åsberg Depression Rating Scale within 1 week after ECT. Multivariate logistic regression analysis was performed to calculate odds ratios (ORs) between different seizure duration groups. Furthermore, the associations between concomitant use of pharmacological treatments, seizure duration, and remission rate were explored. Among the 6998 patients included, 4229 (60.4%) were female and the mean (SD) age was 55.2 (18.6) years. Overall, 2749 patients (39.3%) achieved remission after ECT. Patients with EEG seizure duration of 60 to 69 seconds had the highest remission rates compared with patients with seizure duration of less than 20 seconds (OR, 2.17; 95% CI, 1.63-2.88; P < .001). Anticonvulsant medications were associated with shorter seizure duration (eg, lamotrigine: β coefficient [SE], -6.02 [1.08]; P < .001) and lower remission rates (eg, lamotrigine: adjusted OR, 0.67; 95% CI, 0.53-0.84; P < .001). This study found an association between seizure length and remission from MDD. Use of anticonvulsant medication during ECT was associated with shorter seizure duration and lower remission rates after ECT.

Amplitude-determined seizure-threshold, electric field modeling, and electroconvulsive therapy antidepressant and cognitive outcomes

Electroconvulsive therapy (ECT) pulse amplitude, which dictates the induced electric field (E-field) magnitude in the brain, is presently fixed at 800 or 900 milliamperes (mA) without clinical or scientific rationale. We have previously demonstrated that increased E-field strength improves ECT’s antidepressant effect but worsens cognitive outcomes. Amplitude-determined seizure titration may reduce the E-field variability relative to fixed amplitude ECT. In this investigation, we assessed the relationships among amplitude-determined seizure-threshold (STa), E-field magnitude, and clinical outcomes in older adults (age range 50 to 80 years) with depression. Subjects received brain imaging, depression assessment, and neuropsychological assessment pre-, mid-, and post-ECT. STa was determined during the first treatment with a Soterix Medical 4×1 High Definition ECT Multi-channel Stimulation Interface (Investigation Device Exemption: G200123). Subsequent treatments were completed with right unilateral electrode placement (RUL) and 800 mA. We calculated Ebrain defined as the 90th percentile of E-field magnitude in the whole brain for RUL electrode placement. Twenty-nine subjects were included in the final analyses. Ebrain per unit electrode current, Ebrain/I, was associated with STa. STa was associated with antidepressant outcomes at the mid-ECT assessment and bitemporal electrode placement switch. Ebrain/I was associated with changes in category fluency with a large effect size. The relationship between STa and Ebrain/I extends work from preclinical models and provides a validation step for ECT E-field modeling. ECT with individualized amplitude based on E-field modeling or STa has the potential to enhance neuroscience-based ECT parameter selection and improve clinical outcomes.

Association between pulse width and health-related quality of life after electroconvulsive therapy in patients with unipolar or bipolar depression: an observational register-based study

Aims To examine the association between pulse width and HRQoL measured within one week after electroconvulsive therapy (ECT) and at six-month follow-up in patients with unipolar or bipolar depression. Methods This was an observational register study using data from the Swedish National Quality Registry for ECT (2011–2019). Inclusion criteria were: age ≥18 years; index treatment for unipolar/bipolar depression; unilateral electrode placement; information on pulse width; EQ-5D measurements before and after ECT. Multiple linear regressions were performed to investigate the association between pulse width (<0.5 ms; 0.5 ms; >0.5 ms) and HRQoL (EQ-5D-3L index; EQ VAS) one week after ECT (primary outcome) and six months after ECT (secondary outcome). Results The sample included 5,046 patients with unipolar (82%) or bipolar (18%) depression. At first ECT session, 741 patients (14.7%) had pulse width <0.5 ms, 3,639 (72.1%) had 0.5 ms, and 666 (13.2%) had >0.5 ms. There were no statistically significant associations between pulse width and HRQoL one week after ECT. In the subsample of patients with an EQ-5D index recorded six months after ECT (n = 730), patients receiving 0.5 ms had significantly lower HRQoL (−0.089) compared to <0.5 ms, after adjusting for demographic and clinical characteristics (p = .011). The corresponding analysis for EQ VAS did not show any statistically significant associations. Conclusion No robust associations were observed between pulse width and HRQoL after ECT. On average, significant improvements in HRQoL were observed one week and six months after ECT for patients with unipolar or bipolar disease, independent of the pulse width received.

Electroconvulsive Therapy Across Nations: A 2022 Survey of Practice.

We aimed to characterize worldwide electroconvulsive therapy (ECT) practice and compare practice across nations and global regions. Our anonymous survey was open on SurveyMonkey.com from January to June 2022. We sent invitations to providers identified using a Medicare provider database, an advanced PubMed search function, and professional group listservs. Participants were instructed to submit one survey per ECT site. Response frequencies were pooled by global region and compared using nonparametric methods. Responses came from 126 sites, mostly in the United States (59%, n = 74), Europe (18%, n = 23), Canada (10%, n = 12), and South/East Asia (6%, n = 8). With some exceptions, sites were broadly consistent in practice as indicated by: a likely shift internationally from bitemporal to right unilateral electrode placement; predominant use of pulse widths <1 ms; preference for seizure threshold titration over age-based dosing methods; widespread availability of continuation/maintenance ECT (97%); and frequent use of quantitative outcome measures for depressive symptoms (88%) and cognitive adverse effects (80%). This is the first, published survey that aimed to characterize worldwide ECT practice. With some exceptions, responses suggest a concordance in practice. However, responses were primarily from the Global North. To obtain a truly worldwide characterization of practice, future surveys should include more responses from the Global South.

The Relative Effectiveness of Bilateral and Unilateral Electrode Placement in Electroconvulsive Therapy (ECT) in Patients With Major Depressive Disorder: A Retrospective Cohort Study.

Background This study is focused on the comparative efficacy of bilateral and unilateral electroconvulsive therapy (ECT) on depressive symptoms in patients at the Perth Clinic for the period from 2016 to 2021. Methods This was a retrospective cohort study of 485 patients who received ECT treatment. The expected improvements in depressive symptoms were evaluated by the Depression Anxiety Stress Scale(DASS)assessment tool filled out by the patients on admission and discharge from the hospital. Only the depression score of the DASS scale was utilised for this research. Results The results suggested that both electrode placements resulted in a significant improvement in depressive symptoms. The positive response rates for the bilateral and unilateral electrode placements were 78.3% and 71.6%, respectively. There was no difference between males and females in the average DASS score at discharge for bilateral and unilateral electrode placements. Conclusions This study confirmed that the results obtained at the Perth Clinic are similar to the existing international research results on the same topic. Bifrontal and unilateral ECT electrode placements are equally efficacious in improving depressive symptoms in patients suffering from major depressive disorder (MDD).

Rare adverse effects of Electro Convulsive Therapy

IntroductionECT’s most common side effects are headache, memory impairment, and cardiovascular changes [1]. We report the unusual case of unilateral eyelid swelling and cheek flushing as a side effect of ECT in a depressed but otherwise healthy patient.ObjectivesThe patient is a 53-year-old woman with a recurrent depressive disorder for 15 years with a current major depressive episode without psychotic symptoms. With therapy resistance to mirtazapine (60 mg/d) and lithium (675 mg/d; 0.75 mmol/l), an ECT series with a total of seven sessions were performed. Treatment was performed with right unilateral electrode placement according to d’Elia (RUL).MethodsAfter the first session (Thymatron IV; energy: 20%; pulse width: 0.5; EEG: 45 s), marked hemifacial erythema and supraorbital lid swelling on the right side were evident. After each of the total seven sessions with adequate seizures in the EEG between 45 to 68 s, hemifacial erythema and supraorbital eyelid swelling were evident on the right side.ResultsBoth supraorbital eyelid edema occurred immediately after seizure onset, and hemifacial erythema resolved spontaneously and entirely within 10 minutes after the termination of the respective seizure.ConclusionsThe right side of the face appeared normal before ECT and had no injuries or abnormalities. Trauma, allergic reactions to the anesthetic, or complications of manual ventilation were excluded. In the literature, only one case report with supraorbital eyelid edema [2] and one case report with hemifacial redness of the face [3] after ECT have been described so far. We evaluate the eyelid edema and erythema that occurred in our case as isolated benign complications, most likely due to autonomic activation of facial nerves due to electrical stimulation in RUL.Disclosure of InterestNone Declared

Clinical Practice Guidelines for the Use of Electroconvulsive Therapy.

Clinical Practice Guidelines for the Use of Electroconvulsive Therapy.

Electroconvulsive Therapy Practice in Thailand: A Nationwide Survey.

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

An Examination of Electroconvulsive Therapy and Delivery of Care in Delirious Mania.

Delirious mania is a severe life-threatening syndrome, often misdiagnosed, and eminently treatable as a variant of catatonia. Our aim is to provide a comprehensive examination of electroconvulsive therapy (ECT) parameters and clinical features, as well as describe the delivery of care of the patients with delirious mania. A retrospective study was conducted of the ECT records at Stony Brook University Hospital from years 2014 to 2021. We characterized demographic and clinical variables, including psychiatric diagnoses and ECT parameters of patients identified with delirious mania. We identified 8 cases (3 women) of delirious mania with 8 corresponding acute treatment series. The mean age was 43.2 ± 12.6 years (range, 23-59 years). There were a total of 55 sessions performed with an average of 6.9 ± 2.6 (range, 5-13); 45 (82%) were bilateral (bifrontal or bitemporal) and 10 (18%) were right unilateral electrode placement. In 40 (73%) of the sessions, a high-energy stimulus was used (>60%, or 302 millicoulombs). Seizure duration measured on electroencephalogram was 47.4 ± 25.9 seconds (range, 0-143 seconds). Motor seizure duration measured on electromyogram was 32.7 ± 14.9 seconds (range, 0-66 seconds). In 6 cases, ECT was delayed for 10 days, and patients were given inappropriate treatments. High-dose antipsychotics caused worsened aggression and hemodynamic instability requiring physical restraints in 50% of cases. The clinical presentation of delirious mania remains poorly recognized, and its treatment is often delayed, which may result in negative outcomes. Bilateral ECT with high-energy dosing yielded a rapid remission of symptoms.

Electroconvulsive therapy in treatment resistant depression

Electroconvulsive therapy (ECT) is a treatment modality for patients with treatment resistant depression (TRD), defined as failure of two adequate antidepressant medication trials. We provide a qualitative review of ECT's effectiveness for TRD, methods to optimize ECT parameters to improve remission rates and side effect profiles, and ECT's proposed neurobiological mechanisms. Right unilateral (RUL) electrode placement has been shown to be as effective for major depression as bilateral ECT, and RUL is associated with fewer cognitive side effects. There is mixed evidence on how to utilize ECT to sustain remission (i.e., continuation ECT, psychotropic medications alone, or a combination of ECT and psychotropic medications). Related to neurobiological mechanisms, an increase in gray matter volume in the hippocampus-amygdala complex is reported post-ECT. High connectivity between the subgenual anterior cingulate and the middle temporal gyrus before ECT is associated with better treatment response. Rodent models have implicated changes in neurotransmitters including glutamate, GABA, serotonin, and dopamine in ECT's efficacy; however, findings in humans are limited. Altogether, while ECT remains a highly effective therapy, the neurobiological underpinnings associated with improvement of depression remain uncertain.

Electroconvulsive therapy, electric field, neuroplasticity, and clinical outcomes

Electroconvulsive therapy (ECT) remains the gold-standard treatment for patients with depressive episodes, but the underlying mechanisms for antidepressant response and procedure-induced cognitive side effects have yet to be elucidated. Such mechanisms may be complex and involve certain ECT parameters and brain regions. Regarding parameters, the electrode placement (right unilateral or bitemporal) determines the geometric shape of the electric field (E-field), and amplitude determines the E-field magnitude in select brain regions (e.g., hippocampus). Here, we aim to determine the relationships between hippocampal E-field strength, hippocampal neuroplasticity, and antidepressant and cognitive outcomes. We used hippocampal E-fields and volumes generated from a randomized clinical trial that compared right unilateral electrode placement with different pulse amplitudes (600, 700, and 800 mA). Hippocampal E-field strength was variable but increased with each amplitude arm. We demonstrated a linear relationship between right hippocampal E-field and right hippocampal neuroplasticity. Right hippocampal neuroplasticity mediated right hippocampal E-field and antidepressant outcomes. In contrast, right hippocampal E-field was directly related to cognitive outcomes as measured by phonemic fluency. We used receiver operating characteristic curves to determine that the maximal right hippocampal E-field associated with cognitive safety was 112.5 V/m. Right hippocampal E-field strength was related to the whole-brain ratio of E-field strength per unit of stimulation current, but this whole-brain ratio was unrelated to antidepressant or cognitive outcomes. We discuss the implications of optimal hippocampal E-field dosing to maximize antidepressant outcomes and cognitive safety with individualized amplitudes.

Electroconvulsive therapy practice in a general hospital in chile

IntroductionElectroconvulsive therapy (ECT) is a current, relevant treatment for severe mental illness. In this article we describe our experience on ECT in a public hospital in Chile.ObjectivesDescribe a 34 patients’ cohort who received ECT and their outcomes.MethodsData was extracted from ECT records between 2018-2020, patients’ evaluations before and after ECT, and case files. Data was then analyzed and described.ResultsECT was received by 18 males and 16 females. Age ranged from 19 to 73 years (41 average). More than 75% had 12 or more years of education. Patients’ diagnoses and indications for ECT are shown in Figures 1-2The CGI-SI scale was applied to subjects before treatment, and 85% had a score of 5 or more. On average, patients received 8.7 ECT sessions. Right unilateral electrode placement (RUL) was preferred initially for 94% of patients. Brief pulse width (0.3ms) was most commonly used (76%). Seizure duration averaged in 29 seconds. Adverse reactions presented on 32%, most being mild. One treatment had to be stopped due to confusional symptoms post ECT. After ECT, 91% of patients improved according to CGI-GI scale. 55% were assessed CGI-GI 1 “very much improved”. MoCA scale was also evaluated, showing a 2,1 point gain.ConclusionsSchizophrenia and psychosis were the most frequent diagnosis and indication for ECT. RUL and brief pulse width were the preferred settings. This cohort suggests that ECT had an impact on markedly ill patients, based on CGI and MoCA scales.

Electric field strength induced by electroconvulsive therapy is associated with clinical outcome

The clinical effect of electroconvulsive therapy (ECT) is mediated by eliciting a generalized seizure, which is achieved by applying electrical current to the head via scalp electrodes. The anatomy of the head influences the distribution of current flow in each brain region. Here, we investigated whether individual differences in simulated local electrical field strength are associated with ECT efficacy. We modeled the electric field of 67 depressed patients receiving ECT. Patient’s T1 magnetic resonance images were segmented, conductivities were assigned to each tissue and the finite element method was used to solve for the electric field induced by the electrodes. We investigated the correlation between modelled electric field and ECT outcome using voxel-wise general linear models. The difference between bilateral (BL) and right unilateral (RUL) electrode placement was striking. Even within electrode configuration, there was substantial variability between patients. For the modeled BL placement, stronger electric field strengths appeared in the left hemisphere and part of the right temporal lobe. Importantly, a stronger electric field in the temporal lobes was associated with less optimal ECT response in patients treated with BL-ECT. No significant differences in electric field distributions were found between responders and non-responders to RUL-ECT. These results suggest that overstimulation of the temporal lobes during BL stimulation has negative consequences on treatment outcome. If replicated, individualized pre-ECT computer-modelled electric field distributions may inform the development of patient-specific ECT protocols.

Frequency and Duration of Course of ECT Sessions: An Appraisal of Recent Evidence.

Aims and Method:This paper aims to review the recent literature regarding factors influencing the frequency and number of sessions during a course of electroconvulsive therapy (ECT) for different psychiatric disorders. We systematically reviewed English-language papers of clinical trials of ECT published since the year 2000 in terms of frequency and number of sessions of ECT.Results:None of the 30 studies meeting our inclusion criteria were specifically designed to study frequency or number of sessions of ECT. A preliminary inference may be drawn regarding the number of sessions from the information available in these papers. For depression, patients receiving brief-pulse ECT needed fewer sessions than those receiving ultra-brief ECT when these were delivered at 8-times the threshold with unilateral electrode placement or at 2.5-times the threshold with bilateral placement. For schizophrenia, those receiving bifrontal ECT and ECT at 4-times the threshold-level stimulus needed fewer sessions than those receiving bitemporal ECT and 2-times the threshold-level stimulus, respectively. There were no clinical trials of the frequency of ECT sessions.Clinical Implications:As there is a dearth of studies specifically examining frequency and number of ECT sessions, broad recommendations from professional bodies should continue to guide practice.

COMPARISON OF THE SPEED OF REMISSION BETWEEN BILATERAL AND RIGHT UNILATERAL ECT IN A COHORT OF GERIATRIC PSYCHIATRY PATIENTS

Introduction • Electroconvulsive therapy (ECT) has been clinically proven to be an effective form of treatment for severe depression. It is also a safe treatment option when a quick response is needed. ECT is especially useful in the geriatric population where the complications of severe depression like not eating or drinking, self-neglect, deteriorating medical co morbidities lead to increased morbidity and mortality. •Several studies have compared efficacy of the different electrode placements as well as any resulting cognitive side effects from ECT. • A randomized trial comparing bifrontal, bitemporal and right unilateral electrode placement in ECT (commonly referred to as CORE) showed clinical and statistically significant antidepressant outcomes with all three electrode placements. Bitemporal electrode placement in this study however resulted in a more rapid decline in symptoms over the early course of treatment leading to the recommendation that bitemporal leads be considered the preferred placement for urgent clinical situations. Of note the mean age characteristics of these patients was 53.1 and all carrying a diagnosis of Unipolar/bipolar depression with/without psychosis, receiving acute ECT treatment. • In Phase I of the PRIDE study, a sample of geriatric patients with severe depression were given RUL ECT 3?times a week. One of the secondary outcomes they looked at was the speed of remission which was determined by the number of RUL ECT treatments required to achieve remission. In this study, the mean number of RUL ECT treatments to achieve remission was 7.3. • In this retrospective chart review we hypothesized that using bitemporal electrode placement would lead to remission of symptoms with fewer ECT treatments than right unilateral placement among a strictly geriatric population. • Potentially fewer treatments could lead to lower treatment costs, reduce the risk of cognitive impairment and illness burden by achieving quicker response. Methods •Retrospective chart review of 20 inpatient psychiatry patients all over age 65. Diagnoses included Major depressive disorder with psychosis (6), without psychosis (11), Bipolar disorder, depressed (2) and schizoaffective disorder (1). •All 20 patients received and responded positively to acute ECT treatment at Mount Sinai Hospital administered 3 times a week. •10 patients received bitemporal treatment and 10 received right unilateral treatment. •Treatment outcome was measured by the Quick Inventory of Depressive Symptomatology (QIDS) before each ECT treatment. The QIDS-SR is a self-report inventory that measures depressive symptom severity in the following domains: sleep, psychomotor activity, appetite/weight, sad mood, concentration, energy, interest, guilt and suicidal ideations/intent. • We looked at QIDS scores at baseline and over the course determined how many ECT treatments each group received before their QIDS scores were reduced by 50%. Results Of the 20 patient ECT records reviewed, 11 were male and 9 females. 6 patients were between ages 66-70 and the remaining 14 patients were all above age 70. . At the start of ECT the average QIDS score for patients receiving bitemporal ECT was 19.8 and for RUL was 17. This indicates a moderate to severe depression from the QIDS inventory. . The average number of ECT treatments to achieve 50% QIDS score reduction in bitemporal ECT was 4.5 and that for RUL ECT was 4.1. Conclusions The average number of bitemporal ECT treatments to achieve a QIDS score reduction of 50% was 4.5 whilst that for right unilateral ECT was 4.1. • Patients that received bilateral ECT had higher average QIDS scores of 19.8 suggesting that sicker patients are treated with BL ECT. This could potentially have been because of a perceived need for a quicker response compared to RUL ECT which was not consistent with our findings. •We observed that there was little difference in the number of treatments needed to achieve fifty percent reduction in symptoms. From our findings it appears that in the geriatric population both bitemporal and right unilateral electrode placements have rapid onset of action with only a marginal difference. •Our study was limited by it being a retrospective medical chart review with only 20 patients. This research was funded by: Not Applicable

ECT AMPLITUDE AND CLINICAL OUTCOMES

Introduction ECT is recognized for its efficacy in the treatment of depressive disorders, however neurocognitive impairment remains a major concern of treatment. Demographic factors, depression severity, and ECT treatment parameters influence neurocognitive outcomes. Studies examining ECT electrode placement and pulse width find that more focal stimulus delivery with right unilateral placement or ultrabrief pulse width can reduce cognitive side effects, however are associated with less efficacy than standard treatments. Pulse amplitude, which determines the induced electric field strength in the brain, is currently set at 800-900?mA on modern ECT devices without any clinical or scientific rationale. Lower pulse amplitudes also produce more focal electric fields and potentially reduce neurocognitive impairment. Recent small studies have demonstrated that low amplitude ECT can generate seizure induction, may improve depression severity, and result in fewer cognitive side effects. There are not yet prospective randomized studies examining the antidepressant and neurocognitive dose-response relationship relative of ECT pulse amplitude. The present study compares three different pulse amplitudes during an ECT series. We hypothesize that the lower amplitudes will maintain the antidepressant efficacy of the standard treatment and reduce the risk of neurocognitive impairment. Methods The present study (ClinicalTrials.gov identifier NCT0299929) prospectively randomized subjects to three treatment arms: 600mA, 700mA, and 800mA (active comparator). Clinical, neuropsychological, and imaging assessments were conducted pre-, mid- (after the sixth ECT treatment) and post-ECT (within one week of finishing the ECT series). Subjects had a diagnosis of major depressive disorder, met the clinical indication for ECT, were between 50 and 80?years of age, and right-handed. Depression severity was tracked using the Hamilton Depression Rating Scale 24-item (HDRS-24). The neuropsychological battery is focused on detecting longitudinal differences in hippocampal-dependent changes in cognitive performance. Our primary outcome measure was the Hopkins Verbal Learning Test-Revised (HVLT-R) raw retention score. All subjects were treated with right unilateral electrode placements with either ultrabrief pulse width (0.3 ms) or brief pulse widths (1.0ms, used for the last 14 subjects following interim data analysis). Treatments were individually titrated to supra-threshold, with subsequent treatments given at 6x seizure threshold. Results For this analysis, we focused on subjects that completed all three time points with RUL electrode placement. 62 patients were randomized to the three different pulse amplitude groups and completed at least the first and mid- visits. Demographics, including age, sex, duration of depressive episode, number of lifetime episodes, and baseline cognitive status were not significantly different between groups. Initial HDRS-24 scores were similar. The lowest amplitude group (600 mA) in our study showed significantly less antidepressant effect compared to the higher amplitudes (700mA and 800mA). The amplitude groups did not have significant differences in our primary cognitive outcome, the HVLT-R retention score. Several of the secondary cognitive outcomes were more sensitive to detecting cognitive impairment than the Hopkins Verbal Learning Test, revealing that subjects receiving 800?mA demonstrated greater impairment effects compared to the lower amplitude. This was most sensitive in the Delis Kaplan Executive Function System (DKEFS)-Verbal Fluency subset, DKEFS-Color Word Interference, and Dot Counting Test. Conclusions This study used a blinded randomized design to examine dose-dependent effects of pulse amplitude on depression response and neurocognitive measures. Despite seizure induction, treatment with the 600mA pulse amplitude did not achieve clinical efficacy in comparison to higher amplitudes. These findings support the concept that seizure is necessary but not sufficient for treatment response. The primary cognitive outcome, the Hopkins Verbal Learning Test-Revised (HVLT-R) raw retention score, did not show significant difference between amplitudes. However, neurocognitive battery outcomes of verbal fluency, color-word interference, and dot counting showed sensitivity in the secondary analyses. Focal electric field exposure through reduction of pulse amplitude may be beneficial in limiting the effects of some aspects of cognitive impairment. Limitations of our study include attrition and missing data from for some subjects who could not complete the full neurocognitive battery. Further work on understanding ECT treatment parameters can optimize and individualize care for patients undergoing ECT, maximizing benefit and reducing cognitive risk. This research was funded by: BRAIN Initiative U01 MH111826

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.

When to switch from bilateral to unilateral electroconvulsive therapy: A simple way to elicit seizures in high seizure threshold cases.

AimsAlthough electroconvulsive therapy (ECT) is effective for various psychiatric disorders, its therapeutic effect depends on the occurrence of adequate seizures. Thus, the management of inadequate seizures remains a clinical problem. Here, we aimed to develop a simple method to elicit adequate seizures in high seizure threshold patients during ECT sessions.MethodsRight unilateral ECT was performed in 87 sessions (22 inpatients) in which 504 millicoulombs bilateral (bitemporal or bifrontal) electrical stimulation had failed to induce adequate seizures. A Thymatron® System IV (Somatics LLC, Lake Bluff, IL, USA) and the LOW 0.5 program were used in accordance with the manufacturer's instructions. The electrode placement was bitemporal, bifrontal, or right unilateral (d'Elia placement). The minimum duration for an adequate seizure was 15 seconds in the electroencephalogram record of the Thymatron® stimulator. The efficacy of treatment was estimated by the Global Assessment of Functioning at the time of admission and discharge. Cognitive assessment was not performed.ResultsBy switching to right unilateral stimulation immediately after failure of bilateral stimulation, adequate seizures were achieved in 71 of 87 (81.6%) sessions. Improvement in the Global Assessment of Functioning was observed in 23 of 28 (82.1%) treatment courses.ConclusionSwitching from bilateral to unilateral electrode placement may be a simple clinical option for eliciting adequate seizures in high seizure threshold cases.

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.

ECT Said to Be Valid Alternative For Elderly Patients With Depression

ECT Said to Be Valid Alternative For Elderly Patients With Depression