Clinical Outcomes of Magnetic Seizure Therapy vs Electroconvulsive Therapy for Major Depressive Episode: A Randomized Clinical Trial

Optimal Frequency for Seizure Induction With Electroconvulsive Therapy and Magnetic Seizure Therapy in Nonhuman Primates

Background

Electroconvulsive therapy (ECT) and magnetic seizure therapy (MST) are effective in the treatment of medication-resistant depression. Determining the stimulus frequency that results in the lowest seizure threshold could produce fewer adverse effects by reducing the overall stimulus intensity.

Methods

To determine the optimal frequency for seizure induction, 4 male rhesus macaques were titrated with an increasing number of pulses at fixed frequencies ranging from 5 to 240 pulses per second (pps) using ultrabrief pulse right-unilateral ECT and circular-coil-on-vertex MST. Bilateral electroencephalography was recorded to characterize the seizure expression.

Results

The seizure threshold dependence on stimulus frequency was similar for ECT and MST. While higher frequencies required progressively shorter trains to induce a seizure, the middle frequency range was associated with the fewest pulses (and therefore the least charge and energy), with a minimum at 16 pps and similarly low thresholds for 10 and 25 pps. The number of pulses at seizure threshold increased markedly at lower and higher frequencies. The lowest stimulus frequencies, 5 and 10 pps, were associated with the greatest ictal power measured by electroencephalography.

Conclusions

While neither efficacy nor side effects were assessed in this study, the results highlight the significance of stimulus frequency for seizure induction, suggest efficient titration schedules that minimize exposure to the electrical stimulus, and can inform studies to assess the impact on clinical outcomes. These data can also support safety guidelines for interventions such as transcranial magnetic stimulation that must avoid seizure induction.

An Update on the Use of Neuromodulation Strategies in the Treatment of Schizophrenia

The field of neuromodulation has evolved tremendously and now includes a vast array of interventions utilizing different technologies that span electrical, magnetic, and ultrasound forms of stimulation. The evolution of interventions holds the promise of fewer adverse effects and a noninvasive approach, increasing the scale at which these interventions may be offered in hospital and community settings. While the majority of neuromodulation studies have focused on patients with mood disorders, predominantly depression, there is an unmet need for patients with schizophrenia, who are in dire need of novel therapeutic options. Advances in neuroimaging and approaches for examining individual variability and transdiagnostic symptoms may lead to more effective neuromodulation treatments in this patient population. This overview explores the modern landscape of invasive and noninvasive neuromodulation treatments for patients with schizophrenia. It begins with approaches that involve diffuse stimulation of the cortex and subcortex and then reviews more focal stimulation approaches at the cortical and subcortical levels. The authors also reflect on the relationship between our understanding of the neurobiology of schizophrenia and neuromodulation interventions.

Extended course accelerated intermittent theta burst stimulation as a substitute for depressed patients needing electroconvulsive therapy

In response to restrictions on electroconvulsive therapy (ECT) access during COVID-19, we designed a trial to assess the clinical outcomes service impacts, employing an extended course of accelerated intermittent theta burst stimulation (aiTBS), in patients with moderate to severe depression in need of ECT. This open label clinical trial was comprised of 3 phases: (i) an acute phase, where iTBS treatments were administered 8 times daily, for up to 10 days; (ii) a tapering phase of 2 treatment days per week for 2 weeks, followed by 1 treatment day per week for 2 weeks; and (iii) a symptom-based relapse prevention phase, whereby treatments were scheduled based on symptom re-emergence, for up to 6 months. Of the 155 patients who completed the acute phase of the study, the remission rate was 16.1%. The mean reduction from baseline on the HRSD-24 was 29.4% (p < 0.001) and the response rate was 25.2%. Of the 110 patients who completed the tapering phase, the mean reduction from baseline was 42.6% (p < 0.001) and response and remission rates were 49.6% and 34.8%, respectively. Of the 61 patients who were eligible for the relapse prevention phase, 43 completed, with a mean reduction from baseline of 60.1% (p < 0.001); 7 patients relapsed during this phase. This study demonstrated that an extended aiTBS protocol safely led to meaningful clinical outcomes in patients with severe depression, who otherwise would have received ECT, and thus reduced pressure on ECT services during the pandemic. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04384965 ( https://clinicaltrials.gov/study/NCT04384965?term=NCT04384965&rank=1 ).

Comparing the Neurocognitive Effects of Right Unilateral Ultra-Brief Pulse Electroconvulsive Therapy and Magnetic Seizure Therapy for the Treatment of Major Depressive Episode

BACKGROUND

Magnetic seizure therapy (MST) is under investigation as a treatment for adults with major depression. Previous research has suggested that MST has antidepressant efficacy comparable to that of electroconvulsive therapy (ECT), but with greater cognitive safety. The objective of the study was to compare the neurocognitive outcomes of patients receiving an acute course of MST with the outcomes of those receiving ECT for the treatment of major depressive episode.

METHODS

This was a between-subjects, double-masked, randomized, multicenter clinical trial. Seventy-three participants with a severe major depressive episode were enrolled and randomly assigned to treatment with MST (n = 35) or ultra-brief pulse right unilateral ECT (n = 38). The main outcome was change in performance from baseline to the end of acute treatment on multiple neurocognitive measures.

RESULTS

Compared with patients who received ECT, patients who received MST had superior cognitive outcomes up to 72 hours posttreatment. Specifically, following MST treatment, there was significant improvement in fine motor dexterity (p = .017) and no significant change in cognitive domains of attention, verbal fluency, executive function, or verbal learning and memory. In contrast, following treatment with ECT, patients demonstrated significantly worse performance on measures of verbal fluency (p < .001), executive function (p = .038), and verbal memory retention (p < .001). Autobiographical memory consistency decreased significantly following treatment with both ECT (p < .001) and MST, although the magnitude of change was greater for ECT.

CONCLUSIONS

The study findings confirm previous work and provide new evidence supporting the enhanced cognitive safety of MST relative to ECT. Future research on MST is warranted to optimize its application to individuals with neuropsychiatric illnesses across the life span.

Optimizing Electroconvulsive Therapy With E-Field Modeling: A Narrative Review

ABSTRACT

Electroconvulsive therapy (ECT) is an effective treatment for severe depression, especially in treatment-resistant cases. However, its potential cognitive side effects necessitate careful dosing to balance therapeutic benefits and cognitive stability. Recent advances in electric field (E-field) modeling offer promising avenues to optimize ECT dosing. This review synthesizes current knowledge on E-field modeling in ECT and explores its clinical applications. It examines the variability in E-field strengths and distributions induced by ECT and their impact on clinical outcomes. Additionally, the relationship between E-field strengths, neuroplasticity, and therapeutic efficacy is discussed. Translational studies of E-field-informed ECT are highlighted, emphasizing individualized optimal amplitude dosing and potential clinical applications. This review provides useful insights into how E-field modeling can improve the effectiveness of ECT while minimizing adverse effects, helping guide future research and clinical practice.

Magnetic seizure therapy for unipolar and bipolar depression: An up to date systematic review

BACKGROUND

Magnetic seizure therapy (MST) has emerged as a promising alternative to electroconvulsive therapy (ECT) for treatment-resistant depression. Previous systematic reviews and meta analysis already showed its primary results, however, there are no recent reviews updating these findings.

OBJECTIVES

This systematic review aimed to make an updated systematic review of MST on unipolar and bipolar depression.

METHODS

We conducted a search considering databases (PubMed/MEDLINE, EMBASE, Web of Science, Scopus). Studies were included if they investigated MST in human subjects for unipolar or bipolar depression, and not restricting to year or language.

RESULTS

Data resulted in 15 studies, corresponding to 300 participants that received MST. Most studies were pilot, open-label or secondary analyses (n = 12). Participants that received MST had a response and remission rates ranging from 26.9% to 72.2% and 11.1% to 61.1%, respectively. The most common stimulation regions were vertex and prefrontal cortex, with frequencies between 25-100 Hz and duration of 6-24 sessions (2-3 times a week). Few side effects were reported.

CONCLUSIONS

MST shows to be effective and well-tolerated treatment for depression. Larger, double-blinded RCTs with standardised mood, cognitive, and side effect assessments are needed to confirm these findings.

Magnetic Seizure Therapy in Refractory Psychiatric Disorders: A Systematic Review and Meta-Analysis: La thérapie par convulsions magnétiques pour la prise en charge des troubles psychiatriques réfractaires : revue systématique et méta-analyse

ObjectiveTo qualitatively and quantitatively synthesize the literature on the efficacy and safety of magnetic seizure therapy (MST) in psychiatric disorders.MethodsA literature search was conducted of the OVID Medline, OVID EMBASE, PsychINFO, CINAHL, Web of Science and Cochrane databases from inception to 14 January 2024, using subject headings and key words for "magnetic seizure therapy." Randomized controlled trials (RCTs), post-hoc analyses of RCTs, open-label trials, or case series investigating MST in adults with a verified psychiatric diagnosis and reporting on two possible primary outcomes (1) psychiatric symptom reduction (as measured by validated rating scale) or (2) neurocognitive outcomes (as measured by standardized testing), were included. Abstracts, individual case reports, reviews and editorials were excluded. Extracted data included: (1) basic study details; (2) study design; (3) sample size; (4) baseline demographics; (5) outcome data (including secondary outcomes of suicidal ideation and adverse events); and (6) stimulation parameters. Cochrane's risk of bias tool was applied. A quantitative analysis was conducted for the depression studies, using Hedge's g effect sizes.ResultsA total of 24 studies (n = 377) were eligible for inclusion. Seventeen studies in depression (including three RCTs), four studies in schizophrenia (including one RCT), one study in bipolar disorder, one study in obsessive-compulsive disorder and one study in borderline personality disorder were summarized. We found no significant difference in depressive symptom reduction between MST and electroconvulsive therapy (ECT) in randomized, controlled trials (g = 0.207 towards ECT, 95% confidence interval (CI) -0.132 to 0.545, P = 0.232). We found a significant reduction in depressive symptoms overall with MST in the pooled RCT and open-label analysis (g = 1.749, CI 1.219 to 2.279, P < 0.005). It is suggested that MST has modest cognitive side effects.ConclusionsLarge-scale RCTs are necessary to confirm early signals of MST as an effective intervention in psychiatric disorders with a cognitive profile that is potentially more favourable than ECT.

Electroconvulsive therapy and cognitive performance from the Global ECT MRI Research Collaboration

The Global ECT MRI Research Collaboration (GEMRIC) has collected clinical and neuroimaging data of patients treated with electroconvulsive therapy (ECT) from around the world. Results to date have focused on neuroimaging correlates of antidepressant response. GEMRIC sites have also collected longitudinal cognitive data. Here, we summarize the existing GEMRIC cognitive data and provide recommendations for prospective data collection for future ECT-imaging investigations. We describe the criteria for selection of cognitive measures for mega-analyses: Trail Making Test Parts A (TMT-A) and B (TMT-B), verbal fluency category (VFC), verbal fluency letter (VFL), and percent retention from verbal learning and memory tests. We performed longitudinal data analysis focused on the pre-/post-ECT assessments with healthy comparison (HC) subjects at similar timepoints and assessed associations between demographic and ECT parameters with cognitive changes. The study found an interaction between electrode placement and treatment number for VFC (F(1,107) = 4.14, p = 0.04). Higher treatment was associated with decreased VFC performance with right unilateral electrode placement. Percent retention showed a main effect for group, with post-hoc analysis indicating decreased cognitive performance among the HC group. However, there were no significant effects of group or group interactions observed for TMT-A, TMT-B, or VFL. We assessed the current GEMRIC cognitive data and acknowledge the limitations associated with this data set including the limited number of neuropsychological domains assessed. Aside from the VFC and treatment number relationship, we did not observe ECT-mediated neurocognitive effects in this investigation. We provide prospective cognitive recommendations for future ECT-imaging investigations focused on strong psychometrics and minimal burden to subjects.

Optimal Frequency for Seizure Induction with Electroconvulsive Therapy and Magnetic Seizure Therapy

Electroconvulsive therapy (ECT) and magnetic seizure therapy (MST) are effective in the treatment of medication-resistant depression. Determining the stimulus frequency resulting in the lowest seizure threshold could produce fewer adverse effects by reducing the overall stimulus intensity. To determine the optimal frequency for seizure induction, four male rhesus macaques were titrated with an increasing number of pulses at fixed frequencies ranging from 5 to 240 pulses per second (pps) using ultrabrief-pulse right-unilateral ECT and circular-coil-on-vertex MST. The seizure threshold dependence on stimulus frequency was similar for ECT and MST. While higher frequencies required progressively shorter trains to induce a seizure, the middle frequency range was associated with the fewest pulses (and hence the least charge and energy), with a minimum at 16 pps and similarly low thresholds for 10 and 25 pps. The number of pulses at seizure threshold increased markedly at lower and higher frequencies. The lowest stimulus frequencies, 5 and 10 pps, were associated with the greatest ictal power measured by electroencephalography. While this study did not assess efficacy or side effects, the results highlight the significance of stimulus frequency for seizure induction, suggest efficient titration schedules that minimize exposure to the electrical stimulus, and can inform studies to assess the impact on clinical outcomes.

Magnetic Seizure Therapy vs Modified Electroconvulsive Therapy in Patients With Bipolar Mania: A Randomized Clinical Trial

Importance

Bipolar mania is a common disabling illness. Electroconvulsive therapy (ECT) is an effective treatment for patients with severe mania, though it is limited by the risk of cognitive adverse effects. Magnetic seizure therapy (MST) as an alternative treatment to ECT for bipolar mania has not yet been reported.

Objective

To compare the effectiveness and cognitive adverse effects of MST and ECT in bipolar mania.

Design, Setting, and Participants

This randomized clinical trial was conducted at the Shanghai Mental Health Center from July 1, 2017, through April 26, 2021. Forty-eight patients with bipolar mania were recruited and randomly allocated to receive MST or ECT. The data analysis was performed from June 5, 2021, through August 30, 2023.

Interventions

Patients completed 2 or 3 sessions of MST or ECT per week for a total of 8 to 10 sessions. The MST was delivered at 100% device output with a frequency of 75 Hz over the vertex.

Main Outcomes and Measures

The primary outcomes were reduction of total Young Manic Rating Scale (YMRS) score and response rate (more than 50% reduction of the total YMRS score compared with baseline). An intention-to-treat (ITT) analysis and repeated-measures analyses of variance were conducted for the primary outcomes.

Results

Twenty patients in the ECT group (mean [SD] age, 31.6 [8.6] years; 12 male [60.0%]) and 22 patients in the MST group (mean [SD] age, 34.8 [9.8] years; 15 male [68.2%]) were included in the ITT analysis. The response rates were 95.0% (95% CI, 85.4%-100%) in the ECT group and 86.4% (95% CI, 72.1%-100%) in the MST group. The YMRS reduction rate (z = -0.82; 95% CI, -0.05 to 0.10; P = .41) and response rate (χ2 = 0.18; 95% CI, -0.13 to 0.31; P = .67) were not significantly different between the groups. The time-by-group interaction was significant for the language domain (F1,24 = 7.17; P = .01), which was well preserved in patients receiving MST but worsened in patients receiving ECT. No serious adverse effects were reported in either group.

Conclusions and Relevance

These findings suggest that MST is associated with a high response rate and fewer cognitive impairments in bipolar mania and that it might be an alternative therapy for the treatment of bipolar mania.

Trial Registration

ClinicalTrials.gov Identifier: NCT03160664.