Bifrontal versus right unilateral and bitemporal electroconvulsive therapy in major depressive disorder

OBJECTIVES: We sought to evaluate the safety and efficacy of three electroconvulsive therapy (ECT) methods: moderate-dose bifrontal, low-dose bitemporal, and high-dose right unilateral in the treatment of a major depressive episode. METHODS: In an 8-session, double-blinded parallel group study, 45 consecutive depressive patients who were referred for ECT to Noor Hospital were assigned randomly to bifrontal, moderate dose (50% above seizure threshold; n = 15); bitemporal, low dose (just above seizure threshold; n = 15); and right unilateral, high dose (400% above the seizure threshold; n = 15) ECT applications. Primary outcome measures included assessment by Mini-Mental State Examination and Hamilton Depression Rating Scale. RESULTS: Thirty-nine of the patients completed the course of treatment. Two patients in bifrontal, 1 in bitemporal, and 3 in right unilateral dropped out of the study. The 3 groups did not show any difference in baseline characteristics. There was a significant difference between standardized Mini-Mental State scores of patients in bifrontal group compared with bitemporal and right unilateral patients (P < 0.05). The effectiveness of the 3 ECT methods, assessed by Hamilton Depression Rating Scale, did not show any significant difference (P > 0.05). CONCLUSION: Moderate-dose bifrontal ECT revealed fewer cognitive side effects in comparison with bitemporal and right unilateral. Moderate-dose bifrontal ECT had the same efficacy compared with low-dose bitemporal and high-dose right unilateral in the treatment of depression.     

Bifrontal electroconvulsive therapy in the elderly: a 2-year retrospective

OBJECTIVES: We sought to examine the clinical effect of bifrontal (BF) electroconvulsive therapy (ECT) in depressed patients aged 65 years and older. METHODS: A retrospective chart review of all patients who received BF ECT for a depressive disorder between January 2000 and December 2002 was made. RESULTS: Fourteen patients, with a mean age of 73.9 years, received BF ECT. Nine had unipolar and 5 had bipolar depression. Twelve patients (86%) responded unequivocally after a mean of 8.5 treatments. Five (35%) experienced cognitive side effects. Ninety-two percent of patients were discharged on lithium (0.6 mmol/L) with 86% also receiving antidepressants or antipsychotics. Only 1 patient relapsed, the remainder remaining well at follow-up after a mean of 18.7 months. CONCLUSION: BF ECT was found to be clinically effective and associated with cognitive side effects in elderly patients who were experiencing a depressive episode of either unipolar or bipolar origin.     

Nonconvulsive seizures in electroconvulsive therapy: further evidence of differential neurophysiological aspects of bitemporal versus bifrontal electrode placement

In recent years, attention has been focused on the role of electrode placement in determining efficacy and cognitive side effects of electroconvulsive therapy (ECT). In particular, interest in bifrontal electrode placement has increased. Some evidence indicates differential therapeutic, cognitive, and neurophysiological aspects of bifrontal versus bitemporal ECT. Occasionally in ECT practice, electroencephalographic seizure activity is manifested in the absence of motor convulsive activity, a phenomenon termed nonconvulsive seizures. This probably indicates isolated prefrontal seizure activity in the absence of motor strip involvement. We reviewed our records and found that bifrontally treated patients had a significantly higher incidence of nonconvulsive seizures in ECT than did bitemporally treated patients. Seizure threshold was also higher among the bifrontal patients. We hypothesize that this provides further evidence of differential neurophysiology of seizures induced with these 2 electrode placements.     

Etomidate versus propofol for electroconvulsive therapy in patients with schizophrenia

Among drugs used for the anesthesia of electroconvulsive therapy (ECT), propofol reduces seizure duration to a greater degree than etomidate. The perceived difference between the 2 anesthetics is smaller in patients with schizophrenia than in patients who suffer depression. In this study, propofol and etomidate were compared during the ECT of patients with schizophrenia, on the basis of their impact on seizure activity and on seizure-induced hemodynamic reactions. Schizophrenics (n = 34) who were treated with ECT participated in this randomized crossover study. Propofol (1 mg/kg) and etomidate (0.2 mg/kg) were used alternately. The 2 drugs were compared on the basis of EEG- and EMG-registered seizure duration, mean arterial pressure (MAP), pulse frequency, energy index, and postictal suppression. We also analyzed the number of necessary restimulations. In case of anesthesia with etomidate, both EEG- (61.29 +/- 22.4 s, 47.9 +/- 21.3 s P = 0.014) and EMG- (46.3 +/- 23.8 s, 33.6 +/- 15.9 s P = 0.006) registered seizure durations were significantly longer than in case of propofol. When using propofol, the increase in MAP was significantly lower than when etomidate was used (8.1 +/- 10.2 mm Hg, 18.3 +/- 11.2 mm Hg, P = 0.001). There were no significant differences found in the postseizure increase in pulse frequency, in postictal suppression, or in the energy index, nor did the numbers of necessary restimulations differ significantly. Propofol was found to reduce seizure duration to a significantly greater extent than etomidate. At the same time, in electrophysiological parameters that show a correlation with clinical efficacy, there was no significant difference found between the 2 anesthetics. However, the seizure-induced increase in MAP was reduced by propofol to a significantly greater degree than by etomidate.     

双额侧或双颞侧无抽搐电休克疗法对难治性精神分裂症疗效及记忆功能的影响

目的探讨电极放置位置对无抽搐电休克治疗疗效及对记忆功能影响。方法选择符合入组标准的难治性精神分裂症患者60例,随机分为双额侧组和双颞侧组,各30例,疗效测定使用PANSS量表,于治疗前、治疗第1、4、8、12次后分别测定,记忆功能测定使用wMS量表,分别于治疗前及疗程结束后进行测定。结果治疗前两组PANSS及wMs各项指标差异无统计学意义,第1次治疗后双额侧组PANSS阳性症状及总分开始改善（P〈0．05）,双颞侧组在第4次治疗后才出现改善（P〈0．05）;两组组间比较,第4周两组间阳性症状、阴性症状、总分差异有统计学意义（P〈0．05）;疗程结束后两组间PANSS指标及有效率差异无统计学意义（P〉0．05）。WMS量表显示双额侧组明显比双颞侧带来的记忆功能影响小。结论双额侧电极放置MECT治疗难治性精神分裂症相对双颞侧起效快,疗效相当,对记忆功能影响程度小。     

The effectiveness of real versus simulated electroconvulsive therapy in depressed elderly patients

The results of the Nottingham electroconvulsive therapy (ECT) trial were examined to compare the response of patients aged 60 and over to real versus simulated ECT. The outcome of patients given real compared to simulated ECT was significantly better immediately after six study treatments. Unilateral ECT was an effective as bilateral treatment. The small number of patients studied did not allow for definitive conclusions on whether patients responded sooner to bilateral relative to unilateral treatment.     

Comparison of clinical efficacy and side effects for bitemporal and bifrontal electrode placement in electroconvulsive therapy

OBJECTIVES: Bifrontal (BF) placement of electrodes in electroconvulsive therapy (ECT) has become a popular alternative to bitemporal (BT) placement. This study compares the clinical efficacy, side effects, and rehospitalization rates of BT and BF electrode placement in a community hospital setting. METHODS: Charts from 76 patients receiving ECT treatments at Harborview Medical Center from 1994 to 2000 were reviewed to extract data on the characteristics of the course of ECT, clinical response, total headaches, narcotic and nonsteroidal anti-inflammatory drug doses, as well as documentation of confusion, disorientation, memory loss, and treatment emergent need for assistance with activities of daily living. RESULTS: The BT patients experienced more clinical improvement during their stay (a 7-point greater change in Psychiatric Symptom Assessment Scale score, P < 0.05) and were significantly less likely to be rehospitalized within a 1-year time frame (odds ratio = 4.9, P = <0.05), even after controlling for relevant covariates. Although the two patient groups had equal rates of headache and analgesic administration, the BT placement caused significantly more cognitive impairment. CONCLUSIONS: This study suggests that BT electrode placement offers better efficacy but modestly greater cognitive impairment than BF electrode placement.     

Double-blind randomized controlled study comparing short-term efficacy of bifrontal and bitemporal electroconvulsive therapy in acute mania

Background:  Bifrontal electrode placement is as efficacious as bitemporal placement during electroconvulsive therapy (ECT) in depression but is associated with fewer cognitive adverse effects. There are no studies comparing these techniques in acute mania. This study compared the short-term efficacy and adverse effects of bifrontal and bitemporal ECT in the treatment of acute mania.
Method:  Thirty-six DSM-IV mania inpatients referred for ECT were recruited for study. They were randomized to receive bifrontal (BFECT; n = 17) or bitemporal (BTECT; n = 19) ECT. None of the subjects were on mood stabilizers during the course of ECT. Severity of mania was measured on the Young Mania Rating Scale (YMRS) before beginning ECT and then on Days 3, 7, 11, 14, and 21 of treatment. Cognitive functions were assessed eight hours after the fifth ECT session using the Mini-Mental Status Examination (MMSE), Paired Associate Learning Test, Complex Figure Test, Verbal Fluency Test (animals and fruits categories), and Trail Making Test, Part A.
Results:  The subjects in the two groups were comparable on sociodemographic and clinical variables, including severity of mania at baseline. They were also similar in ECT parameters, including seizure threshold and seizure duration. Mean YMRS scores showed faster decline in the BFECT than in the BTECT group. Kaplan–Meier survival analysis showed that a greater proportion of subjects in the BFECT group responded (50% reduction in YMRS score) significantly earlier than in the BTECT group. There were no significant differences between the groups in performance on cognitive function tests.
Conclusion:  In this pilot study, mania patients treated with BFECT responded faster than those treated with BTECT, with comparable cognitive adverse effects. Since ECT is usually prescribed for rapid control of symptoms, BFECT may be preferred over BTECT in the treatment of acute mania.     

Systematic review and meta-analysis of bifrontal electroconvulsive therapy versus bilateral and unilateral electroconvulsive therapy in depression

Abstract

Objectives. Our aim was to perform a meta-analysis of randomized controlled trials comparing efficacy and side effects of bifrontal (BF) ECT to bitemporal (BT) or unilateral (RUL) ECT in depression. Methods. We performed a systematic review of randomized controlled trials comparing BF ECT with RUL or BT ECT in depression. Eight trials (n = 617) reported some cognitive outcome. Efficacy was measured by reduction in Hamilton Depression Rating Scale score. Cognitive outcomes were limited to Mini-Mental State Examination (MMSE) in seven studies, with two studies measuring each of: Complex-figure delayed recall, Trail-making tests and verbal learning. Results. Efficacy was equal between BF and BT ECT (Hedges's g = 0.102, P = 0.345, confidence interval (CI): –0.110, 0.313) and BF and RUL ECT (standardized mean difference = –0.12, P = 0.365, CI: –0.378, 0.139). Post-treatment MMSE score decline was less for BF than BT ECT (g = 0.89, CI: 0.054, 1.724) but not RUL ECT. RUL ECT impaired Complex figure recall more than BF ECT (g = 0.76, CI :0.487, 1.035), but BF ECT impaired word recall more than RUL ECT (g = –1.45, CI: –2.75, –0.15). Conclusions. Bifrontal ECT is not more effective than BT or RUL ECT but may have modest short-term benefits for specific memory domains. BF ECT has potential advantages, but given longer experience with BT and RUL, bifrontal ECT requires better characterization.     

Anesthesia for electroconvulsive therapy: propofol versus thiopental

The anesthesia for sismotherapy is characterized by its briefness and repetitiveness, resulting in several imperatives: anesthesia of short duration, deep narcosis with muscular relaxation and ambulatory character. Thus anesthesic drugs should have a fast onset of action, in order to obtain a rapid and as alert as possible post anesthesia awakening. The objective of this study is to compare two anesthesic drugs: propofol versus thiopentone. We included in this study patients referred to our unit by the psychiatric service for sismotherapy, which was carried on under general anesthesia in the awakening room of the anesthesia department of Ibn Rochd University hospital. 7 of our patients received sismotherapy for schizophrenia, 2 for acute mania and 1 for suicidal depression. A total of 40 sessions of sismotherapy were analyzed, distributed in two groups: group I (n = 20): benefitted of a general anesthesia by thiopentone, the dose was 2 to 3 mg/kg; group II (n = 20): benefitted of general anesthesia by propofol, the dose was 1 to 1.5 mg/kg. Sismotherapy was carried out only once narcosis was considered as deep. To monitor our patients we used electrocardioscope and pulpe oxymeter. We evaluated the quality and especially the time of onset of anesthesia, its duration, the quality of narcosis, the degree of muscular relaxation, respiratory and cardiovascular parameters as well as side effect linked to anesthesia drugs and sismotherapy. Analysis of the results showed that the quality of anesthesia was excellent for both groups. The necessary dose for narcosis was 202 mg for thiopentone and 167 mg for propofol, time of onset of narcosis was 30 seconds for propofol and 45 seconds for thiopentone, anesthesia and the quality of muscular relaxation were considered deep for the two groups. Many authors showed that propofol is the most efficient agent in anesthesia for sismotherapy due to its brief delay of action and faster reversibility. As for thiopentone despite its convulsive properties and poor hemodynamic tolerance, it still is a good hypnotic in anesthesia for sismotherapy when administered at appropriate dose by slow injection. This is due on the one hand to easy administration, lesser incidence of side effects and on the other hand to brief duration of action and low cost. We conclude that thiopentone can be recommended in anesthesia for sismotherapy owing to good properties: deepness of anesthesia, good awakening, tolerance and lower cost.     

Resolution of severe suicidality with a single electroconvulsive therapy

Electroconvulsive therapy is a rapid and effective treatment of severe depression that has been shown to quickly decrease or eliminate suicidal thoughts and behaviors. We describe the case of an 88-year-old man hospitalized for a carefully premeditated suicide attempt with highly lethal means. He was treated with a single electroconvulsive therapy (ECT) and improved markedly. His suicidal ideation remitted, and the patient was still free of suicidal ideation at 5 months of follow-up. We discuss the effect of ECT on suicidal ideation, the benefit of minimizing the number of total ECT treatments, and the possible biological markers of change after a single treatment in an ECT-naive patient.     

Treatment of mania: a naturalistic study of electroconvulsive therapy versus lithium in 438 patients

The efficacy of electroconvulsive therapy (ECT), adequate lithium therapy, inadequate lithium therapy, and neither ECT nor lithium therapy was compared by reviewing the charts of 438 patients hospitalized because of mania over a 12-year period. A significantly (p less than .05) greater percentage (78%) of patients who received ECT had "marked improvement" than did those who received either adequate or inadequate lithium treatment (62% and 56%, respectively) or neither treatment (37%). Of the patients with schizoaffective disorder, manic type, 87.5% who received ECT showed "marked improvement"; almost 70% of patients who failed to respond to adequate lithium had "marked improvement" with ECT. Unilateral and bilateral ECTs were equally effective. Psychosis was not useful in predicting treatment response. ECT was demonstrated to be an effective treatment for mania.