The influence of concomitant antidepressant medication on safety,tolerability and clinical effectiveness of electroconvulsive therapy

Background: A major problem in the treatment of severe depression is the onset latency until clinical improvement. So far, electroconvulsive therapy (ECT) is the most effective somatic treatment of depression. This holds especially true for treatment-refractory disturbances. However, not all patients respond to conventional unilateral ECT. In certain cases, subsequent clinical response can be achieved using bilateral or high-dose unilateral ECT. Also, a concomitant pharmacotherapy can be utilized to augment therapeutic effectiveness. Surprisingly, data in this field are widely lacking and only few studies showed advantages of an ECT/tricyclic antidepressant combination. Method: We retrospectively evaluated 5482 treatments in 455 patients to investigate possible therapeutic advantages in combination therapies versus ECT monotherapy. Main outcome criteria were clinical effectiveness and tolerability. Moreover, treatment modalities and ictal neurophysiological parameters that might influence treatment outcome were analysed. Results: A total of 18.2% of our treatments were ECT monotherapy, 8.87% were done with one antidepressant. Seizure duration was unaffected by the most antidepressants. SSRI caused a lengthened seizure activity. Postictal suppression was lower in mirtazapine and higher in SSRI and SNRI treated patients. A significant enhancement of therapeutic effectiveness could be seen in the patient group receiving tricyclics, SSRI or mirtazapine. Serious adverse events were not recorded. Conclusion: Our study supports the hypothesis that mirtazapine can be used to enhance the therapeutic effectiveness of ECT. Controlled studies are necessary to further investigate the possible advantages of ECT and pharmacotherapy combinations, especially the use of modern dually acting antidepressants which have proven their good effectiveness in treatment-resistant depression.     

The use of electroconvulsive therapy in old age psychiatry

All patients receiving electroconvulsive therapy (ECT) under the care of the Old Age Psychiatry service at the University Hospital of South Manchester between 1976 and 1982 were studied. Data on 193 courses were collected. Eighty per cent of patients were well or considerably improved at discharge. When relapses occurred they usually responded well to antidepressant treatment and did not indicate a poor outcome in the long term. The results confirm that ECT is a safe and effective treatment for elderly patients with severe depressive illnesses, despite the fact that many of them suffer from concurrent physical problems and that some have evidence of intellectual impairment.     

The influence of age on the natural history of unipolar depression when treated with electroconvulsive therapy

Summary The influence of age on the natural history of unipolar depression when treated with electroconvulsive therapy (ECT) was studied using a naturalistic/archival study design. A sample of 125 patients who received no somatic treatment were compared with 128 patients who all received a course of ECT with at least four treatments. Patients were separated according to age at admission. Treated patients, aged 40 or older, who were clearly remitters showed no differences in previous episodes, subsequent episodes, subsequent hospitalizations, or likelihood of experiencing a period of full recovery when compared with a similar group of untreated patients. Hospitalization greater than 1 year and chronicity were significantly more common in the untreated older subjects. Treated patients aged 39 or younger, who also were clearly remitters, showed significant increases in subsequent episodes and subsequent hospitalizations when compared with a group of depressed patients of similar age who received no somatic treatment. Hospitalization greater than 1 year was also more common in the untreated younger patients. ECT clearly reduces the rate of chronicity in older patients but may be associated with an increase in episodes after treatment in the younger population.     

精神分裂症患者血清催乳素对电抽搐治疗的反应

对20例女性精神分裂症患者进行ECT-1前30分钟与后5、15、30和60分钟的血清催乳素(PRL)水平测定,其中10例做了ECT-6的复查。结果,ECT-1后PRL水平迅速显著升高,15分钟达最高峰。提示ECT具有急性抗多巴胺和神经阻滞剂样作用。ECT-6前的PRL基础水平较ECT-1前显著升高,ECT-6后PRL的释放较ECT-1显著下降,表明在多次ECT后异常的多巴胺代谢得到了纠正。     

Electrocardiographic changes following electroconvulsive therapy

Summary This paper reports a study of the effects of ECT (electroconvulsive therapy) upon cardiac function (as judged by electrocardiographic changes) in 24 patients who were given 139 treatments in all. Of the 24 patients 13 were studied over a 24-h period using monitoring equipment. No potentially dangerous arrhythmias were encountered. Modified ECT was found to give rise to sinus tachycardia, which was considerably more prolonged than previously reported. The tachycardia was shown in some cases to be accompanied by a depression of the ST segment and may hence be potentially harmful to those with pre-existing ischaemic heart disease. In such patients consideration should be given to the prior administration of -adrenergic blocking drugs and/or oxygen.     

Antidepressant effects, of magnetic seizure therapy and electroconvulsive therapy, in treatment-resistant depression

Major depression is a common mental health problem and associated with significant morbidity and mortality, including impaired social and physical functioning and increased risk for suicide. Electroconvulsive therapy (ECT) is highly efficacious in treatment-resistant depressive disorders, but cognitive side effects are frequently associated with the treatment. Magnetic seizure therapy (MST) is a form of convulsive therapy, using magnetic fields in order to induce therapeutic seizures. First studies suggested that cognitive side effects of MST, including postictal recovery time, are more benign than those resulting from ECT treatment. In this open-label study we tested the hypothesis that MST is associated with clinically significant antidepressant effects in treatment-resistant depression (TRD) as an add-on therapy to a controlled pharmacotherapy.Twenty patients suffering from TRD were randomly assigned to receive either MST or ECT starting from July 2006 until November 2008. Primary outcome measure was antidepressant response assessed by Montgomery Åsberg Depression Scale. Secondary outcome measures included Hamilton Depression Rating Scale, Hamilton Anxiety Scale, Beck Depression Inventory and 90-Item Symptom Checklist.Antidepressant response (improvement of 50% in MADRS ratings) was statistically significant and of similar size in both treatment groups. Cognitive side effects were observed in neither group. Characteristics in MST- and ECT-induced seizures were comparable, especially regarding ictal activity and postictal suppression. Thus, MST may be a potential alternative to ECT if efficacy and safety are validated in larger clinical trials.     

Post-dexamethasone cortisol as a predictor for the efficacy of electroconvulsive therapy in depressed inpatients

Background

Although several variables have been studied as a possible predictor for the efficacy of ECT, results regarding hypercortisolism have been inconsistent. This prospective study evaluates the relation between pre-treatment cortisol levels and the efficacy of ECT in a population of drug-free inpatients with severe major depression.

Methods

At the inpatient depression unit, 18 patients meeting the DSM-IV criteria for depressive disorder, and with scores of at least 18 on the 17-item Hamilton Rating Scale for Depression (HAM-D), were treated with bilateral ECT twice weekly. The HAM-D evaluated depression severity and was performed within 3 days prior to ECT, weekly during the course of ECT, and within 3 days after the last treatment. The outcome criterion was defined a priori as the change on the HAM-D score. Salivary cortisol was assessed within 3 days prior to ECT at two time points, followed by 0.5 mg dexamethasone ingestion. The following day, salivary cortisol was again assessed at two time points. The generalized linear model was used to assess the relation between salivary cortisol levels and reduction in HAM-D score as continuous variables.

Results

Higher levels of salivary cortisol at 9 AM after 0.5 mg dexamethasone ingestion are associated with a greater reduction in HAM-D score (B = −0.279, 95% CI: −0.557 to −0.01, s.e. = 0.13, p = 0.049; R square = 0.23; adjusted R square = 0.13).

Conclusion

This study suggests that higher levels of post-dexamethasone salivary cortisol at 9 AM are predictive of ECT efficacy.     

Predicting efficacy of electroconvulsive therapy in major depressive disorder

The aim of this study was to investigate methods for predicting the efficacy of electroconvulsive therapy (ECT) in patients with major depressive disorder. Subjects comprised 24 inpatients with major depressive disorder diagnosed according to DSM-IV criteria who were resistant to antidepressant therapy or who, due to adverse reactions, could not undergo pharmacotherapy at adequate doses for sufficient durations. ECT was generally performed 12 times using a sinusoidal-wave device. Efficacy of ECT was evaluated using the 17-item Hamilton Rating Scale for Depression (HRSD). Multiple regression analysis was performed, using the final rate of improvement with ECT as the dependent variable, and improvement rate at completion of three ECT sessions and adequacy of pharmacotherapy before ECT as independent variables. Significant positive correlations were seen between final improvement rate with ECT and improvement rate at completion of three ECT sessions (partial correlation coefficient, 0.50, P<0.02), and significant negative correlations were seen between final improvement rate and adequacy of pharmacotherapy before ECT (partial correlation coefficient, -0.51, P<0.02). No significant differences were identified between responders and non-responders with respect to age, sex, duration of index episode, number of previous depressive episodes, whether depression was melancholia-type, whether depression was accompanied by psychotic features, total HRSD score immediately before ECT, and HRSD retardation or agitation scores. These results suggest that history of pharmacotherapy prior to ECT and improvement rate at completion of three ECT sessions may offer predictors for the final rate of improvement with ECT.     

The influence of anaesthetic medication on safety,tolerability and clinical effectiveness of electroconvulsive therapy

Background: Electroconvulsive therapy (ECT) is still considered the most effective biological treatment strategy in psychiatric disorders. However, the clinical efficacy of ECT may be affected by stimulus variables and the concomitant use of psychopharmacological medication. Furthermore, most anaesthetics have anticonvulsant properties and therefore might additionally influence the efficacy of ECT. Method: In order to explore whether different anaesthetics might alter the effectiveness or safety of ECT we retrospectively analyzed 5482 ECT treatments in 455 patients. Anaesthetics were chosen according to clinical reasons and comprised thiopental, methohexital, propofol and etomidate. Results: Seizure duration was significantly affected by the anaesthetic medication with longest seizure activity during thiopental anaesthesia. In addition, postictal suppression, a further prospective parameter of ECT effectiveness, was significantly higher during propofol and thiopental anaesthesia. The clinical effectiveness was significantly better during propofol and thiopental anaesthesia. In contrast, the overall safety did not differ between the anaesthetic groups. Conclusion: Our study supports the hypothesis that inducting anaesthetic agents have a different impact on seizure duration, ictal and postictal electrophysiological indices and clinical efficacy of ECT. Compared to thiopental, which has been established as a standard anaesthetic during ECT, also the modern anaesthetic propofol is a suitable inducting agent.     

Involuntary and voluntary electroconvulsive therapy: A case-control study

Background

It is not known whether results of clinical research in ECT can be used to guide treatment decisions for those having involuntary ECT, who are not represented in trial populations.

A systematic review and meta-analysis of randomized controlled trials of adjunctive ketamine in electroconvulsive therapy: Efficacy and tolerability

BackgroundElectroconvulsive therapy (ECT) remains one of the most effective tools in the psychiatric treatment armamentarium, particularly for refractory depression. Yet, there remains a subset of patients who do not respond to ECT or for whom clinically adequate seizures cannot be elicited, for whom ketamine has emerged as a putative augmentation agent.MethodsWe searched EMBASE, PsycINFO, CENTRAL, and MEDLINE from 1962 to April 2014 to identify randomized controlled trials evaluating ketamine in ECT (PROSPERO #CRD42014009035). Clinical remission, response, and change in depressive symptom scores were extracted by two independent raters. Adverse events were recorded. Drop-outs were assessed as a proxy for acceptability. Meta-analyses employed a random effects model.ResultsData were synthesized from 5 RCTs, representing a total of 182 patients with major depressive episodes (n = 165 Major Depressive Disorder, n = 17 Bipolar Disorder). ECT with ketamine augmentation was not associated with higher rates of clinical remission (Risk Difference (RD) = 0.00; 95%CI = −0.08 to 0.10), response (RD = −0.01; 95%CI = −0.11 to 0.08), or improvements in depressive symptoms (SMD = 0.38; 95%CI = −0.41 to 1.17). Ketamine augmentation was associated with higher rates of confusion/disorientation/prolonged delirium (OR = 6.59, 95%CI: 1.28–33.82, NNH = 3), but not agitation, hypertension or affective switches.ConclusionOur meta-analysis of randomized controlled trials of ketamine augmentation in the ECT setting suggests a lack of clinical efficacy, and an increased likelihood of confusion. Individuals for whom adequate seizures or therapeutic response cannot be obtained have not been studied using randomized controlled designs. Additional research is required to address the role of ketamine in this population.     

Relationship of electroconvulsive therapy to course in affective illness: A collaborative study

Bipolars treated with electroconvulsive therapy (ECT) during the index episode were matched on the variables of age, sex, previous admissions and previous hospitalizations with 23 bipolars who did not receive ECT. A similar match was made for 42 unipolars who were under the age of 40 at time of admission. All patients were followed for 5 years. Those patients treated with ECT, both bipolars and unipolars, had the same numbers of episodes in follow-up as their matched groups. However, in both bipolar and unipolar ECT-treated patients, there were more follow-up rehospitalizations. The reason for this is not known but three possibilities exist. Successful treatment with ECT may make the family and patient more prone to consider rehospitalization. Secondly, the originally treated ECT patients may have had more aggressive doctors who were more likely to rehospitalize. Finally, ECT may change the course of an individual's illness in such a way that more severe episodes occur and rehospitalizations are necessary. The findings suggest the need for long-term studies following ECT on clinical and biological variables.     

Seizure duration in unilateral electroconvulsive therapy

ABSTRACT– Seizure duration in unilateral electroconvulsive therapy (ECT) was recorded by means of EEG in an intraindividual comparison under different alveolar O₂- and CO₂-concentrations. Hypocapnia induced by hyperventilation to an alveolar CO₂-concentration of 2 % (2 kPa) resulted in a highly significant increase in seizure duration compared to a normal CO₂ of 5 %, when the alveolar O₂-concentration was constant at 92 %. Oxygen ventilation to an alveolar O₂-concentration of 92 % gave no significant increase in seizure duration compared to 15 %, obtained by ventilation with air, when the CO₂-concentration was kept constant at 5 %. Seizure duration seems to augment progressively with decreasing alveolar CO₂-concentration.     

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.     

Heart rate variability increases in elderly depressed patients who respond to electroconvulsive therapy

OBJECTIVES: To evaluate the parasympathetic modulation in elderly inpatients with major depressive disorder (MDD) before and after electroconvulsive therapy (ECT) using both linear and nonlinear methods of heart rate variability (HRV) analysis. METHOD: A measure of local dimensional complexity (pointwise correlation dimension, PD2), as well as spectral analysis measures (LF, low-frequency range; HF, high-frequency range) were calculated for the heart rate time series of 10 elderly inpatients with MDD (70+/-7 years) before and after ECT. Hamilton Depression Rating Scale (HAM-D) was evaluated concomitantly. RESULTS: Only the responders to ECT (n=7; >or=50% reduction in HAM-D) exhibited a significant increase in PD2 (P=.0035), which showed a tendency towards a correlation with symptom improvement (r=.73, P=.06). Spectral analysis measures did not show a significant difference after ECT. CONCLUSION: Elderly patients with MDD, who respond to ECT, might show increased vagal modulation. Since nonlinear HRV measures have been shown to be reduced by aging, similar to cholinergic deficit, they might shed light on the increased risk for cardiac mortality in depression.     

不同麻醉深度对抑郁症电休克治疗后学习记忆的影响

目的观察抑郁症在不同麻醉深度下行电休克治疗的疗效及对学习记忆的影响。方法75例初次接受电休克治疗的抑郁症患者,随机分为A、B、C三组,每组25例。A组:单次静脉推注丙泊酚1.5 mg/kg后实施电休克;B组:丙泊酚泵注维持深麻醉(脑电双频指数<45)下电休克;C组:丙泊酚泵注维持临床麻醉深度(脑电双频指数=45～60)下电休克。于电休克治疗前、治疗后24 h和1周末以17项汉密尔顿抑郁量表和韦氏记忆量表评估抑郁症状及学习记忆功能。结果与C组比较,A组、B组呼吸恢复时间、意识恢复时间、治疗室观察时间均延长(P<0.05)。三组患者电休克治疗后24 h(F=5.04,P<0.01)及1周末(F=4.05,P<0.05)汉密尔顿抑郁量表评分较治疗前均降低,而在各时间点评分三组之间差异无统计学意义。与治疗前比较,三组患者ECT后24 h长时记忆均降低(P<0.05),而ECT后24 h和1周后患者短时记忆、即刻记忆均升高(P<0.05),且B组、C组短时记忆、即刻记忆高于A组(P<0.05)。结论临床麻醉深度下实施电休克治疗可有效缓解抑郁症状,且患者的短期记忆在治疗后可得到早期改善,有利于患者早期康复,更适于电休克的麻醉。     

Current progress in neuroimaging research for the treatment of major depression with electroconvulsive therapy

Electroconvulsive therapy (ECT) uses a certain amount of electric current to pass through the head of the patient, causing convulsions throughout the body, to relieve the symptoms of the disease and achieve the purpose of treatment. ECT can effectively improve the clinical symptoms of patients with major depression, but its therapeutic mechanism is still unclear. With the rapid development of neuroimaging technology, it is necessary to explore the neurobiological mechanism of major depression from the aspects of brain structure, brain function and brain metabolism, and to find that ECT can improve the brain function, metabolism and even brain structure of patients to a certain extent. Currently, an increasing number of neuroimaging studies adopt various neuroimaging techniques including functional magnetic resonance imaging (MRI), positron emission tomography, magnetic resonance spectroscopy, structural MRI, and diffusion tensor imaging to reveal the neural effects of ECT. This article reviews the recent progress in neuroimaging research on ECT for major depression. The results suggest that the neurobiological mechanism of ECT may be to modulate the functional activity and connectivity or neural structural plasticity in specific brain regions to the normal level, to achieve the therapeutic effect.     

首次无抽搐电休克治疗后迟发性谵妄1例

无抽搐电休克治疗(MECT)是在传统电休克治疗基础上配合麻醉技术,是一种快速、安全、高效的治疗方法。MECT虽减少了因抽搐而产生的不良反应,但仍存在头痛、肌肉疼痛、认知功能损害等副作用。本文报告了1例MECT治疗后谵妄(PECTD)的案例,并对PECTD发生的可能机制进行探讨,考虑发作时间过长、双侧电极片放置是本例发生PECTD的可能原因。提示临床工作者加强对PECTD的预防、识别。