The ictal EEG in ECT: A systematic review of the relationships between ictal features,ECT technique,seizure threshold and outcomes

ObjectiveTo provide guidance for ECT practitioners in utilising the ictal EEG to inform treatment decisions.MethodsA systematic review of studies examining the ictal EEG, treatment technique, seizure threshold and treatment outcomes was conducted. MEDLINE, EMBASE and PsycINFO databases were searched up to July 31, 2019. Studies were included if they examined the use of ECT in human subjects and compared an ictal EEG analysis (either quantitative or manually rated) with either: a) clinical outcomes, b) seizure threshold/threshold change, c) ECT dosing decisions, or d) different aspects of ECT technique (comparison of different electrode placements, pulse widths, waveforms, or dose/dose relative to seizure threshold).ResultsA total of 853 studies were identified, with 44 meeting inclusion criteria. A qualitative review revealed ictal EEG indices have been linked to therapeutic outcome, though the strength of this relationship appears modest. Ictal EEG features are influenced by variations in ECT treatment technique. Serial ictal EEG monitoring can detect changes in seizure threshold across an ECT course for right unilateral brief and ultrabrief pulse ECT.ConclusionWhile there is some relationship between ictal EEG manifestation and treatment outcomes, the primary utility of ictal EEG monitoring during an ECT course may lie in the capacity to detect changes in seizure threshold and adjust dosing accordingly. Prospective validation of a dosing regime informed by serial ictal EEG monitoring is warranted.     

Hue-specific colour memory impairment in an individual with intact colour perception and colour naming

Cases of hue-selective dyschomatopsias, together with the results of recent optical imaging studies [Xiao, Y., Casti, A. R. R., Xiao, J., & Kaplan, E. (2006). A spatially organized representation of colour in macaque primary visual cortex. Perception, 35, ECVP Abstract Supplement; Xiao, Y., Wang, Y., & Felleman, D. J. (2003). A spatially organized representation of colour in macaque cortical area V2. Nature, 421, 535-539], have provided support for the idea that different colours are processed in spatially distinct regions of extrastriate cortex. In the present report, we provide evidence suggesting that a similar, but distinct, map may exist for representations of colour in memory. This evidence comes from observations of a young woman (QP) who demonstrates an isolated deficit in colour memory secondary to a concussive episode. Despite having normal colour perception and colour naming skills, and above-average memory skills in other domains, QP's ability to recall visually encoded colour information over short retention intervals is dramatically impaired. Her long-term memory for colour and her colour imagery skills are also abnormal. Surprisingly, however, these impairments are not seen with all hues; specifically, her ability to remember or imagine blue shades is spared. This interesting case contributes to the literature suggesting that colour perception, naming, and memory can be clinically dissociated, and provides insights into the organization of colour information in memory.     

The efficiency of ECT: I. Response rate in depressive episodes

A great deal of variation in opinion and practice remains regarding the most efficient use of electroconvulsive therapy (ECT) in treating depression. In this study we used an estimate of maximal improvement point to look at the rate of response to conventional ECT (one seizure per session, three times per week) in 66 patients with depressive episodes. Of the variables examined, increasing age was found to be significantly associated with slower response rate. Comparison of our results with studies of the multiple seizure technique suggests that giving multiple seizures per session does not speed response rate. We therefore conclude that within the limits of current clinical practice age is probably more important than number of frequency of seizures in determining the rate at which depression responds to ECT.     

A two-site,open-label,non-randomized trial comparing Focal Electrically-Administered Seizure Therapy (FEAST) and right unilateral ultrabrief pulse electroconvulsive therapy (RUL-UBP ECT)

BackgroundFocal Electrically-Administered Seizure Therapy (FEAST) is a form of electroconvulsive therapy (ECT) that spatially focuses the electrical stimulus to initiate seizure activity in right prefrontal cortex. Two open-label non-comparative studies suggested that FEAST has reduced cognitive side effects when compared to historical data from other forms of ECT. In two different ECT clinics, we compared the efficacy and cognitive side effects of FEAST and Right Unilateral Ultrabrief Pulse (RUL-UBP) ECT.MethodsUsing a non-randomized, open-label design, 39 depressed adults were recruited after referral for ECT. Twenty patients received FEAST (14 women; age 45.2 ± 12.7), and 19 received RUL-UBP ECT (16 women; age 43.2 ± 16.4). Key cognitive outcome measures were the postictal time to reorientation and the Columbia University Autobiographical Memory Interview: Short-Form (CUAMI-SF). Antidepressant effects were assessed using the Hamilton Rating Scale for Depression (HRSD₂₄).ResultsIn the Intent-to-treat sample, a repeated measures mixed model suggested no between group difference in HRSD₂₄ score over time (F_1,35 = 0.82, p = 0.37), while the response rate favored FEAST (FEAST: 65%; RUL-UBP ECT: 57.9%), and the remission rate favored RUL-UBP ECT (FEAST: 35%; RUL-UBP ECT: 47.4%). The FEAST group had numeric superiority in average time to reorientation (FEAST: 6.6 ± 5.0 min; RUL-UBP ECT: 8.8 ± 5.8 min; Cohens d = 0.41), and CUAMI-SF consistency score (FEAST: 69.2 ± 14.2%; RUL-UBP ECT: 63.9 ± 9.9%; Cohens d = 0.43); findings that failed to meet statistical significance.ConclusionsFEAST exerts similar efficacy relative to an optimal form of conventional ECT and may have milder cognitive side effects. A blinded, randomized, non-inferiority trial is needed.     

ECT: An essential therapy in psychiatry

At a time when innovations in psychiatry are booming, particularly in the field of medical devices, we thought it necessary, as members of French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), to reconsider one of the oldest medical devices in psychiatry: the ECT apparatus. First, we recall the regulatory aspects of ECT. National guidelines define means of implementation and conditions of administration of ECT. Second, we remind of the indications and levels of evidence of ECT in the main psychiatric disorders, including catatonia. Then, we synthetize the place of ECT alongside other brain stimulation therapies, especially repetitive Trancranial Magnetic Stimulation (rTMS). Furthermore, we explain the general effects of ECT: increased neuronal plasticity and neurogenesis, enhancement of the stress axis, resistance to oxidative stress, improved vascular endothelial function, activation of microglia and astrocytes, decrease in inflammatory events by upregulation of neuroinflammatory cytokines, and production of mitochondrial ATP. These effects appear from the first sessions and continue during the course of ECT treatment, suggesting activation of endogenous neuroprotection. Finally, we remember that most patients perform as well or better on neuropsychological assessments after ECT, relative to pre-ECT results, and this improvement continues over the following months. Memory disorders reported post-ECT are not all attributable to ECT. They may be subjective in nature or linked to residual depressive (and possibly comorbid neurogenerative) symptoms later attributed to ECT, on the basis of preexisting negative representations. We urgently need to reemphasize the crucial role of ECT in psychiatric treatment strategies as well as the need to update ECT recommendations.     

The Behavioral Dyscontrol Scale as a Predictor of Aggression against Self or Others in Psychogeriatric Inpatients

The ability of the Behavioral Dyscontrol Scale (BDS) and its factors to predict aggression in psychogeriatric inpatients was investigated. Fifty-one neurologic and 33 psychiatric patients participated in the study. In the psychiatric group, Environmental Independence Factor (EIF: consisting of two go/no-go tasks) was more impaired in aggressive than in nonaggressive patients. In both groups, Fluid Intelligence Factor (FIF: consisting of alphanumeric sequencing, non-mirroring, and insight) was more impaired in aggressive than in nonaggressive patients. No differences between aggressive and nonaggressive patients were found for the Motor Programming Factor, BDS total score, or Mini-Mental State Exam. Receiver Operating Characteristic (ROC) curve using an EIF/FIF composite demonstrated high sensitivity and modest specificity for the psychiatric patients, yielding an Area Under the Curve (AUC) of 84%. Differences in the test’s ability to predict aggression in the two diagnostic groups underscore the necessity for establishing unique norms for different populations.     

The effects of ECT on cognitive functioning in the elderly: a review

BACKGROUND: Electroconvulsive therapy (ECT) as a single course or in maintenance form (M-ECT) is an effective treatment in depressed elderly. However, ECT may have adverse effects on cognition. OBJECTIVE: To review all studies from 1980-2006 on ECT and cognition in the elderly with a minimum age of 55 years or a mean age of 55 years, and with valid measurements of cognition before and after ECT. RESULTS: Nine out of the 15 eligible studies were focused exclusively on the elderly. Three studies reported verbal learning- and recall problems post ECT, while three studies found positive effects of ECT on memory, speed of processing and concentration. Global cognitive functioning in patients with cognitive impairment improved in all studies. At follow up, most studies reported improvement of cognitive functions. Learning verbal information and executive functioning were impaired in M-ECT patients whereas global cognition remained stable after M-ECT over a year. CONCLUSIONS: To date research of ECT on cognitive functioning in the elderly is very limited. Small sample size, lack of controls, use of a single screening instrument and a short follow up period may explain the conflicting results. Given the clinical importance, more extensive research on cognition in elderly treated with ECT is urgently needed.     

Combining ECT with pharmacological treatment of depressed inpatients in a naturalistic study is not associated with serum BDNF level increase

BackgroundBDNF blood levels are reduced in MDD. They can be increased with pharmacologic treatment and ECT, but it is not clear whether the combination of treatments promotes an additional increase. The present study aims to evaluate whether combined treatment promotes an increase in BDNF, restoring the level to that of non-depressed controls.MethodsNinety-nine adult inpatients were invited to participate in this naturalistic prospective cohort study between May 2011 and April 2013. Diagnosis was made by MINI, and the symptoms were evaluated at admission and at discharge by HDRS-17. Those inpatients with a diagnosis of depression were included and divided into two groups: those who underwent combined ECT and medication (31 subjects) and those who used only pharmacotherapy (68 subjects). Serum BDNF was measured in blood samples collected at admission and discharge. One hundred healthy blood donors without any psychiatric diagnosis were included as a control group.ResultsThere were no significant differences in serum BDNF levels between the combined and pharmacological groups at admission and at discharge, and no significant variation in BDNF occurred in any group during the treatment. There were no interactions between time and treatment groups nor significant time effects or treatment group effects for BDNF in the Generalized Estimating Equation Model (GEE). The control group had significantly higher serum BDNF levels in comparison with each of the treatment groups at admission and discharge (p = 0.00).ConclusionCombination of ECT with pharmacological treatment did not result in increased serum BDNF levels and did not restore levels to that of controls.     

Electroconvulsive therapy in patient with psychotic depression and multiple sclerosis

Safety of electroconvulsive therapy (ECT) in depressive patients with multiple sclerosis (MS) is still discussed and based solely on case reports. This kind of therapy was used in both unipolar depression and depression in bipolar disorder. It was suggested that ECT might cause the deterioration of neurological state (new MS lesions in magnetic resonance imaging). Moreover, there were also data indicating some anesthesiological complications and difficulties in patients with MS. We have presented a case of a patient who was treated with ECT and developed grand mal seizure after 14th electroconvulsive treatment.     

Variations in myo-inositol in fronto-limbic regions and clinical response to electroconvulsive therapy in major depression

Though electroconvulsive therapy (ECT) is an established treatment for severe depression, the neurobiological factors accounting for the clinical effects of ECT are largely unknown. Myo-inositol, a neurometabolite linked with glial activity, is reported as reduced in fronto-limbic regions in patients with depression. Whether changes in myo-inositol relate to the antidepressant effects of ECT is unknown.Using magnetic resonance spectroscopy (¹H-MRS), we measured dorsomedial anterior cingulate cortex (dmACC) and left and right hippocampal myo-inositol in 50 ECT patients (mean age: 43.78, 14 SD) and 33 controls (mean age: 39.33, 12 SD) to determine cross sectional effects of diagnosis and longitudinal effects of ECT. Patients were scanned prior to treatment, after the second ECT and at completion of the ECT index series. Controls were scanned twice at intervals corresponding to patients’ baseline and end of treatment scans. Myo-inositol increased over the course of ECT in the dmACC (p = 0.042). A significant hemisphere by clinical response effect was observed for the hippocampus (p = 0.003) where decreased myo-inositol related to symptom improvement in the left hippocampus. Cross-sectional differences between patients and controls at baseline were not detected. Changes in myo-inositol observed in the dmACC in association with ECT and in the hippocampus in association with ECT-related clinical response suggest the mechanisms of ECT could include gliogenesis or a reversal of gliosis that differentially affect dorsal and ventral limbic regions. Change in dmACC myo-inositol diverged from control values with ECT suggesting compensation, while hippocampal change suggested normalization.     

Delirium during the course of electroconvulsive therapy in a patient on lithium carbonate treatment

Objective

The safety of concurrent mood stabilizers during the course of electroconvulsive therapy (ECT) is yet to be clearly established. Delirium with concurrent administration of ECT and lithium carbonate is described in this case report.

Methods

A 30-year-old male with a past history of significant head injury developed delirium during the course of bitemporal ECT.

Results

The clinical picture and the details of the cognitive impairment have been discussed in the report with a focus on relationship between the lithium carbonate administration and the concurrent ECT.

Conclusion

Patients with preexisting organic brain damage could be prone to develop the cognitive adverse effect while on a combination of lithium and ECT. Possible interactions between lithium and ECT need further systematic evaluation.     

Challenges in comparing the acute cognitive outcomes of high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) vs. electroconvulsive therapy (ECT) in major depression: A systematic review

The present study aimed to systematically compare the cognitive outcomes of high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) and electroconvulsive therapy (ECT) in head-to-head studies with major depression (MDD) patients. A systematic literature search identified six studies with 219 MDD patients that were too heterogeneous to reliably detect meaningful differences in acute cognitive outcomes after ECT vs. HF-rTMS. Cognitive effects of brain stimulation vary depending on the timeframe and methods of assessment, stimulation parameters, and maintenance treatment. Thus, acute and longer-term differences in cognitive outcomes both need to be investigated at precisely defined timeframes and with similar instruments assessing comparable functions.     

Drug and ECT treatment of depression in the elderly, 1996-2001: a literature review.

A computer-based literature search of all antidepressant and electroconvulsive therapy (ECT) treatment studies published between 1995 and September 2001 was conducted. In addition, a review of published chapters, review articles, and metaanalyses was also conducted. Articles were categorized into those reporting comparative studies, those in which the therapeutic agent was not compared with another, articles about ECT, and review articles. These recent publications support the conclusions from prior reviews that antidepressants and ECT are effective and safe treatments for depressed elderly patients. Differences in efficacy and side effects appear to be slight among the various types of antidepressants. Research studies of depressed elderly increased markedly since 1995 compared with all previous years although more studies are still necessary.     

The prediction of recovery using a multivariate model in 1471 depressed inpatients

Summary Stepwise multiple logistic regression was used in an attempt to develop a statistical model which would predict recovery in a group of 1471 depressives admitted to a tertiary care hospital. Six variables identified by this approach included: Electroconvulsive therapy, personality disorder, chronicity, anxiety disorder, organic mental disorder, and dysthymia. The meaning and significance of the findings are discussed.     

Combination of lithium and electroconvulsive therapy (ECT) is associated with higher odds of delirium and cognitive problems in a large national sample across the United States

BackgroundLithium is a helpful adjunct to patients undergoing ECT. However, only case reports and limited data suggest increase risk of delirium. Thus, this continues to be a controversial issue.ObjectiveIn this study, we examine 1) The association and odds of delirium and cognitive problems with ECT and lithium (ECT + Li) combination compared to ECT alone, 2) If positively associated, would this association vary by both type of mood episode and type of disorder?MethodsA national sample of 64,728 adult psychiatric inpatients across the US (identified from a total data of about 70 million total discharges annually) was analyzed using linear-by-linear association and logistic regression to assess the odds ratio (OR) for delirium and cognitive impairment for those treated with lithium (N = 158), ECT (N = 64148), or ECT + Li (N = 422) after adjusting for demographics and psychiatric diagnoses.ResultsThe prevalence of delirium was higher in the ECT + Lithium group (5.7%) vs. ECT only (0.6%) or lithium only groups (0%). Patients managed with ECT + Lithium have 11.7-fold higher odds (95% CI 7.55–17.99, P < 0.001) of delirium compared to ECT alone. In the ECT + Li group, delirium prevalence was 7.8% in unipolar depression, 3.4% in bipolar depressed, 0% in bipolar mania.ConclusionThese results are surprising given the fading concern about delirium association with ECT + lithium combination. The high odds in the combination group warrant clinical caution, use of lower lithium doses (if combinations cannot be avoided), and vigilance regarding early signs of delirium. These results warrant replication in future studies.     

The architecture of the colour centre in the human visual brain: new results and a review

We have used the technique of functional magnetic resonance imaging (fMRI) and a variety of colour paradigms to activate the human brain regions selective for colour. We show here that the region defined previously [Lueck et al. (1989) Nature, 340, 386-389; Zeki et al. (1991) J. Neurosci., 11, 641-649; McKeefry & Zeki (1997) Brain, 120, 2229-2242] as the human colour centre consists of two subdivisions, a posterior one, which we call V4 and an anterior one, which we refer to as V4alpha, the two together being part of the V4-complex. The posterior area is retinotopically organized while the anterior is not. We discuss our new findings in the context of previous studies of the cortical colour processing system in humans and monkeys. Our new insight into the organization of the colour centre in the human brain may also account for the variability in both severity and degree of recovery from lesions producing cerebral colour blindness (achromatopsia).