ECT in Parkinson's disease-dopamine transporter visualised by [123I]-beta-CIT SPECT

Electroconvulsive Therapy for Parkinson's Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Electroconvulsive therapy (ECT) is a well-established treatment for psychiatric disorders, including depression and psychosis. ECT has been reported to be effective in treating such psychiatric symptoms in patients with Parkinson's disease (PD) and has been also reported to be effective in treating motor symptoms. The aim of the study is to summarize previous clinical studies investigating the efficacy of ECT for symptoms in patients with PD.

METHODS

A systematic review and meta-analysis of any study designs assessing motor and/or non-motor symptoms in patients with PD before and after ECT. Co-primary outcomes were set as motor manifestations assessed using the Unified Parkinson's Disease Rating Scale or other rating scales, and non-motor symptoms included depression and psychosis. Secondary outcomes were wearing-off phenomenon and cognitive function. The impact of ECT on those symptoms was examined by comparing the severity of the symptoms before and after ECT using a random effect model and was expressed in standardized mean difference.

RESULTS

Of 1219 identified citations, 14 studies (n = 129; 1 randomized controlled study, 9 prospective observational studies, and 4 retrospective studies) were analyzed. The findings were as follows: ECT significantly improved motor manifestations in patients with PD, and the improvement was significant in the subpopulation without psychiatric symptoms; ECT significantly improved depression and psychosis; and ECT significantly relieved wearing-off phenomenon and did not worsen cognitive functioning.

CONCLUSION

The current meta-analysis suggests the potential benefit of ECT on motor and non-motor symptoms in presumably complicated and difficult-to-treat subgroups. © 2020 International Parkinson and Movement Disorder Society.

Prolactin changes during electroconvulsive therapy: A systematic review and meta-analysis

BACKGROUND

Early studies reported a prolactin surge during electroconvulsive therapy (ECT). The aim of this study is to review and meta-analyze data on ECT-related prolactin changes.

METHOD

A systematic review and meta-analysis was conducted for trials investigating prolactin changes in ECT-treated patients using standard mean differences (SMD, 95% confidence intervals). Subgroup analyses included comparisons of ECT-related prolactin changes in women vs. men, patients receiving different anesthetics, bilateral vs. unilateral and high-vs. low-dose ECT.

RESULTS

In six trials including 109 ECT-treated patients and 74 controls, prolactin changes were larger in ECT-treated patients than in controls (SMD = 0.89, 95%CI = 0.55, 1.23, p < 0.001 and 1.03, 95%CI = 0.31, 1.75, p = 0.005 for the fixed and random-effect model respectively), despite heterogeneity in the samples (I² = 72%, τ² = 0.62). Effects were led by differences in patients premedicated with methohexital (SMD = 1.14, 95%CI = 0.7, 1.57, p < 0.001 for both fixed and random-effect model). A meta-regression reported significant age effects (coefficient estimate 2.32, 95%CI = -0.73, 3.91, p < 0.01). Additionally, prolactin changes were larger in ECT-treated women than men (SMD = 0.88, 95%CI = 0.58, 1.18, p < 0.001 and 0.99, 95%CI = 0.22, 1.75, p = 0.012 for the fixed and random effect model). Bilateral ECT-treated patients had larger increase than unilateral ECT-treated patients (SMD = -0.81, 95%CI = -1.35, -0.27, p = 0.003 and -0.86, 95%CI = -1.46, -0.25, p = 0.006 for the fixed and random-effect model). Comparisons between high- and low-dose ECT-treated patients could not be conducted. The quality of the studies was overall poor, with four exceptions.

DISCUSSION

Patients receiving ECT had larger prolactin increases than controls. Increases were larger in methohexital-premedicated patients, women vs. men and patients with bilateral vs. unilateral ECT.

Electroconvulsive therapy decreases striatal dopamine transporter binding in patients with depression: A positron emission tomography study with [18F]FE-PE2I

Electroconvulsive therapy (ECT) is an effective treatment for major depression. Previous studies suggested that dopaminergic neurotransmission plays a crucial role in the mechanism of the action of ECT. Since dopamine transporters (DAT) regulate extracellular dopamine concentration, DAT represents an interesting target for the study of the mechanism of action of ECT. Eight inpatients (7 patients with major depressive disorder and 1 patient with bipolar disorder with a DSM-IV diagnosis) received a series of 7-15(11.3±5.2) bilateral ECT sessions.The severity of symptoms was assessed using the 21-item Hamilton Depression Rating Scale (HDRS) and Clinical Global Impression-Severity (CGI-S). All patients were examined with [¹⁸F]FE-PE2I positron emission tomography (PET) at pre-ECT, after the 10^th ECT, and at post-ECT. Striatal DAT-binding potential (BP_ND) of all patients was reduced, with an average change ratio of DAT-BP_ND of -13.1±5.6%. In the 2 cases with 15 ECT sessions, the ratio change of DAT-BP_ND after the 15th ECT was larger than that after the 10th ECT. Also, HDRS and CGI-S were reduced. These results indicate that the dopamine nervous system is part of themechanism of action of ECT.

Electroconvulsive therapy for depression in Parkinson's disease: systematic review of evidence and recommendations

AIM

We performed a systematic review of evidence regarding treatment of depression in Parkinson's disease (PD) utilizing electroconvulsive therapy.

METHODS

The search led to the inclusion of 43 articles, mainly case reports or case series, with the largest number of patients totaling 19.

RESULTS

The analysis included 116 patients with depression and PD; depression improved in 93.1%. Where motor symptoms' severity was reported, 83% of patients improved. Cognition did not worsen in the majority (94%). Many patients experienced delirium or transient confusion, sometimes necessitating discontinuation of electroconvulsive therapy (ECT). Little is known about maintenance ECT in this population.

CONCLUSION

ECT can benefit patients suffering from PD and depression. We recommend an algorithm for treatment of depression in PD, utilizing ECT sooner rather than later.

Glial cell-line derived neurotrophic factor is essential for electroconvulsive shock-induced neuroprotection in an animal model of Parkinson's disease

Sustained motor improvement in human patients with idiopathic Parkinson's disease has been described following electroconvulsive shock (ECS) treatment. In rats, ECS stimulates the expression of various trophic factors (TFs), some of which have been proposed to exert neuroprotective actions. We previously reported that ECS protects the integrity of the rat nigrostriatal dopaminergic system against 6-hydroxydopamine (6-OHDA)-induced toxicity; in order to shed light into its neuroprotective mechanism, we studied glial cell-line derived neurotrophic factor (GDNF) levels (the most efficient TF for dopaminergic neurons) in the substantia nigra (SN) and striatum of 6-OHDA-injected animals with or without ECS treatment. 6-OHDA injection decreased GDNF levels in the SN control animals, but not in those receiving chronic ECS, suggesting that changes in GDNF expression may participate in the ECS neuroprotective mechanism. To evaluate this possibility, we inhibit GDNF by infusion of GDNF function blocking antibodies in the SN of 6-OHDA-injected animals treated with ECS (or sham ECS). Animals were sacrificed 7 days after 6-OHDA infusion, and the integrity of the nigrostriatal system was studied by tyrosine hydroxylase immunohistochemistry and Cresyl Violet staining. Neuroprotection observed in ECS-treated animals was inhibited by GDNF antibodies in the SN. These results robustly demonstrate that GDNF is essential for the ECS neuroprotective effect observed in 6-OHDA-injected animals.

ECT in a patient with Parkinson's disease and schizophrenia, with dopamine transporter visualisation using 123I-ioflupane SPET

A 58-year old woman with chronic schizophrenia developed worsening parkinsonian symptoms over the previous 6 years, and was eventually diagnosed as having Parkinson's disease. Antipsychotics were stopped because they worsened these symptoms. Antiparkinsonian treatment led to a significant increase in delusions and behavioural disorganisation. The patient underwent electroconvulsive-therapy which improved both her psychiatric and motor symptoms. After treatment, 123I-Ioflupane uptake was mildly increased in the left caudate nucleus, but uptake in right caudate nucleus was lower than in a pretreatment scan.

Protection of dopaminergic neurons by electroconvulsive shock in an animal model of Parkinson’s disease

Electroconvulsive shock (ECS) improves motor function in Parkinson's disease. In rats, ECS stimulates the expression of various factors some of which have been proposed to exert neuroprotective actions. We have investigated the effects of ECS on 6-hydroxydopamine (6-OHDA)-injected rats. Three weeks after a unilateral administration of 6-OHDA, 85-95% nigral dopaminergic neurons are lost. Chronic ECS prevented this cell loss, protect the nigrostriatal pathway (assessed by FloroGold retrograde labeling) and reduce motor impairment in 6-OHDA-treated animals. Injection of 6-OHDA caused loss of expression of glial cell-line derived neurotrophic factor (GDNF) in the substantia nigra. Chronic ECS completely prevented this loss of GDNF expression in 6-OHDA-treated animals. We also found that protected dopaminergic neurons co-express GDNF receptor proteins. These results strongly suggest that endogenous changes in GDNF expression may participate in the neuroprotective mechanism of ECS against 6-OHDA induced toxicity.

Non-invasive brain stimulation for Parkinson's disease: a systematic review and meta-analysis of the literature

A systematic review and meta-analysis were conducted to quantify the efficacy of transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT) for the treatment of motor dysfunction in patients with Parkinson's disease (PD). Prospective studies which evaluated the effects of either TMS (12 studies) or ECT (five studies) on motor function in PD using the motor subscale of the Unified Parkinson's Disease Rating Scale (UPDRS) for TMS studies and any continuous measures of motor function in PD for ECT studies were included. The pooled effect size (standardised mean difference between pre-treatment versus post-treatment means) from a random effects model was 0.62 (95% confidence interval: 0.38, 0.85) for TMS treatment and 1.68 (0.79, 2.56) for ECT treatment, and from a fixed effects model was 0.59 (0.39, 0.78) for TMS treatment and 1.55 (1.07, 2.03) for ECT treatment. TMS, across applied stimulation sites and parameters, can exert a significant, albeit modest, positive effect on the motor function of patients with PD. ECT also may exert a significant effect on motor function in PD patients.

The effect of electroconvulsive shock seizures on behaviour induced by dopaminergic agonists and on immobility in the Porsolt test

Male, Wistar rats were given a course of eight electroconvulsive shock seizures (ECS group) or matched handling (control group). They were then tested for locomotion and rearing (7 days post-ECS), for grooming and yawning (9 days post-ECS), and for immobility in the Porsolt test (7, 14 and 21 days post-ECS). Seven days post-seizure, the ECS group showed significantly more locomotion following intraperitoneal administration of apomorphine (0.2 mg/kg), but not following injections of amphetamine (1 mg/kg). Drug-induced rearing was not different in the ECS and control animals. Nine days post-seizure, the ECS group showed significantly more grooming induced by the D-1 dopamine receptor agonist, SKF 38393 (1 mg/kg), but no difference in the yawning induced by the D-2 dopamine receptor agonist, quinpirole (0.05 mg/kg). In the Porsolt test, immobility was decreased in the ECS animals at 7 and 14, but not at 21 days post-ECS. It is concluded that ECS increases activity in the dopaminergic systems of the rat brain for at least 1-2 weeks post-seizure. The beneficial effects of electroconvulsive therapy (ECT) may relate to these dopaminergic alterations.