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Methfessel I, Zilles-Wegner D, Kunze-Szikszay N, Belz M. Effects of Anesthesia Changes During Maintenance ECT: A Longitudinal Comparison of Seizure Quality Under Anesthesia Using Propofol/Esketamine Versus Methohexital. PHARMACOPSYCHIATRY 2023. [PMID: 37116539 DOI: 10.1055/a-2058-9010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
INTRODUCTION The effectiveness of ECT relies on the induction of a generalized cerebral seizure. Among others, seizure quality (SQ) is potentially influenced by the anesthetic drug used. Commonly used anesthetics comprise barbiturates, etomidate, propofol, and esketamine, with different characteristics and impacts on seizure parameters. So far, no studies have compared the influence of methohexital vs. a combination of propofol/esketamine on established SQ parameters. METHODS This retrospective longitudinal study compared eight established SQ parameters (PSI, ASEI, MSC, midictal amplitude, motor and electroencephalography (EEG) seizure duration, concordance, PHR) before and after the change from propofol/esketamine to methohexital in 34 patients under maintenance ECT. Each patient contributed four measurements, two before and two after the anesthesia change. Anesthesia dose, stimulus dose, electrode placement, and concomitant medication remained unchanged throughout the analyzed treatments. RESULTS Under methohexital (M=88.97 mg), ASEI (p=0.039 to 0.013) and midictal amplitude (p=0.022 to<0.001) were significantly lower, whereas seizure duration (motor and EEG) was significantly longer when compared to propofol/esketamine (M=64.26 mg/51.18 mg; p=0.012 to<0.001). PSI, MSC, seizure concordance, and PHR were not affected by the anesthetic used. DISCUSSION Although to what extent these parameters correlate with the therapeutic effectiveness remains ambiguous, a decision for or against a particular anesthetic could be considered if a specific SQ parameter needs optimization. However, no general superiority for one specific substance or combination was found in this study. In the next step, anesthetic effects on treatment response and tolerability should be focused on.
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Affiliation(s)
- Isabel Methfessel
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany
| | - David Zilles-Wegner
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany
| | - Nils Kunze-Szikszay
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Belz
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany
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Cinderella MA, Nichols NA, Munjal S, Yan J, Kimball JN, Gligorovic P. Antiepileptics in Electroconvulsive Therapy: A Mechanism-Based Review of Recent Literature. J ECT 2022; 38:133-137. [PMID: 34739420 DOI: 10.1097/yct.0000000000000805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Although prior conventional wisdom strongly recommended complete discontinuation of medications increasing the seizure threshold before electroconvulsive therapy (ECT), more recent literature suggests that anticonvulsants should be considered a relative rather than an absolute contraindication to proceeding with therapy. Most literature regarding the use of use antiepileptic drugs in ECT focuses on antiepileptic mood stabilizers with which most psychiatrists are familiar. However, there is considerably less information available about the use of newer antiepileptics in conjunction with ECT, which may be prescribed to a patient with epilepsy or off-label for psychiatric reasons.In this article, we provide a mechanism-based review of recent available literature concerning the use of antiepileptics during ECT and discuss which medications have the most robust evidence supporting their continued use in select patients. Finally, we highlight important considerations for psychiatrists when deciding how to proceed with patients on antiepileptics who require ECT.
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Affiliation(s)
- Margaret A Cinderella
- From the Department of Psychiatry and Behavioral Health, Wake Forest School of Medicine and Wake Forest Baptist Health, Winston-Salem, NC
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Factors Predicting Ictal Quality in Bilateral Electroconvulsive Therapy Sessions. Brain Sci 2021; 11:brainsci11060781. [PMID: 34204783 PMCID: PMC8231613 DOI: 10.3390/brainsci11060781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/04/2021] [Accepted: 06/10/2021] [Indexed: 11/16/2022] Open
Abstract
In electroconvulsive therapy (ECT), ictal characteristics predict treatment response and can be modified by changes in seizure threshold and in the ECT technique. We aimed to study the impact of ECT procedure-related variables that interact during each session and might influence the seizure results. Two hundred and fifty sessions of bilateral ECT in forty-seven subjects were included. Seizure results were evaluated by two different scales of combined ictal EEG parameters (seizure quality index (SQI) and seizure adequacy markers sum (SAMS) scores) and postictal suppression rating. Repeated measurement regression analyses were performed to identify predictors of each session’s three outcome variables. Univariate models identified age, physical status, hyperventilation, basal oxygen saturation, days between sessions, benzodiazepines, lithium, and tricyclic antidepressants as predictors of seizure quality. Days elapsed between sessions, higher oxygen saturation and protocolized hyperventilation application were significant predictors of better seizure quality in both scales used in multivariate models. Additionally, lower ASA classification influenced SQI scores as well as benzodiazepine use and lithium daily doses were predictors of SAMS scores. Higher muscle relaxant doses and lower applied stimulus intensities significantly influenced the postictal suppression rating. The study found several modifiable procedural factors that impacted the obtained seizure characteristics; they could be adjusted to optimize ECT session results.
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McGrane IR, Tenison RE, Bimler DM, Munjal RC, Molinaro JR. Successful bilateral electroconvulsive therapy in a patient with a seizure disorder taking levetiracetam, lorazepam, and zonisamide: A case report. Ment Health Clin 2021; 11:23-26. [PMID: 33505822 PMCID: PMC7800328 DOI: 10.9740/mhc.2021.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Electroconvulsive therapy (ECT) may be considered for treatment of severe, treatment-resistant, and emergent depression associated with MDD or bipolar disorder. Patients with epilepsy usually take medications that raise the seizure threshold, which poses challenges during ECT. We report a 66-year-old male with epilepsy taking levetiracetam extended-release (XR), lorazepam, and zonisamide requiring ECT for severe MDD. After literature review, the XR form of levetiracetam was changed to higher doses of the immediate-release (IR) formulation, and zonisamide was discontinued 2 days prior to ECT in the hospital and was resumed when the patient underwent outpatient continuation ECT. The patient was treated to remission after receiving 8 acute bilateral ECT treatments before being transitioned to continuation ECT. We provide a brief review of medication management of antiepileptic drugs and other medications that increase the seizure threshold during ECT. To our knowledge, this is the first reported case describing the management of levetiracetam, lorazepam, and zonisamide concomitantly during ECT. Our case suggests that utilizing the IR formulation of levetiracetam, administering the evening dose early the day prior to the procedure, and temporarily discontinuing zonisamide prior to bilateral ECT is effective for the treatment of severe MDD while maintaining seizure prophylaxis.
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Affiliation(s)
- Ian R McGrane
- PGY-1 Pharmacy Resident, Providence St Patrick Hospital, Department of Pharmacy, Missoula, Montana.,Student, Skaggs School of Pharmacy, College of Health, The University of Montana, Missoula, Montana.,Psychiatrist, Providence St Patrick Hospital, Department of Psychiatry, Missoula, Montana.,Psychiatrist, Providence St Patrick Hospital, Department of Psychiatry, Missoula, Montana
| | - Rachel E Tenison
- PGY-1 Pharmacy Resident, Providence St Patrick Hospital, Department of Pharmacy, Missoula, Montana
| | - Dana M Bimler
- Student, Skaggs School of Pharmacy, College of Health, The University of Montana, Missoula, Montana
| | - Robert C Munjal
- Psychiatrist, Providence St Patrick Hospital, Department of Psychiatry, Missoula, Montana
| | - Jason R Molinaro
- Psychiatrist, Providence St Patrick Hospital, Department of Psychiatry, Missoula, Montana
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Janjua AU, Dhingra AL, Greenberg R, McDonald WM. The Efficacy and Safety of Concomitant Psychotropic Medication and Electroconvulsive Therapy (ECT). CNS Drugs 2020; 34:509-520. [PMID: 32342484 DOI: 10.1007/s40263-020-00729-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Electroconvulsive therapy (ECT) is an effective treatment for severe psychiatric disorders. Patients referred to ECT are often taking multiple medications, many of which can potentially affect the safety and efficacy of their course of ECT. This review evaluates the impact of a variety of psychotropic medications often used in conjunction with ECT and examines strategies to optimize their management. The review encompasses mood stabilizers, antidepressants, benzodiazepines, antiepileptics, antipsychotics, and other commonly used psychotropics.
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Affiliation(s)
- A Umair Janjua
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, NE, Atlanta, GA, 30329, USA.
| | - Amitha L Dhingra
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, NE, Atlanta, GA, 30329, USA
| | | | - William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, NE, Atlanta, GA, 30329, USA
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[Electroconvulsive therapy in combination with psychotropic and non-psychotropic pharmacological treatments: Review of the literature and practical recommendations]. L'ENCEPHALE 2020; 46:283-292. [PMID: 32151451 DOI: 10.1016/j.encep.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 11/21/2022]
Abstract
CONTEXT Electro-convulsive therapy (ECT) is the most effective treatment for treatment resistant mood disorders and catatonia. ECT also appears to be an effective treatment in combination with clozapine in the context of treatment resistant schizophrenia spectrum disorders. Although increasingly codified (guidelines on indications, contraindications, methods of implementation), the practice of ECT still lacks consensual protocols. The concomitant use of psychotropic and/or non-psychotropic medication is a common situation when ECT treatment is considered. To our knowledge, there is to date no summary of studies or case reports in France, nor any proposal for guidelines concerning the management of medication of the patient to whom ECT sessions are offered. Indeed, several particularities must be considered. This article proposes to specify for each pharmacological class the possible interaction between ECT and medication. A first section of this article will be devoted to non-psychotropic treatments, and a second section to psychotropic treatments. A practical summary table is also provided. METHOD A review of the literature was conducted including all articles published prior to January 2019 referenced in Pub Med database, combining research with Medical Subject Headings "Electroconvulsive Therapy" and each following pharmacological class: "Cardiovascular Agents" "Bronchodilator Agents" "Bronchoconstrictor Agents" "Theophylline" "Anticoagulants" "Hypoglycemic Agents" "Insulin" "Potassium" "Benzodiazepines" "Valproic Acid" "Carbamazepine" "Lamotrigine" "Lithium" "Antidepressive Agents" "Antipsychotic Agents". RESULTS After reading the titles, abstracts and whole articles, then searching for additional articles in the references, 50 articles were selected. A summary table summarizing the main risks and proposing a course of action has been produced. DISCUSSION It is essential to take into account the specificity and the different physiological mechanisms involved in the ECT treatment in order to adjust the associated pharmacological treatments. The prescription for each molecule should be reviewed when ECT treatment is initiated.
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Belz M, Methfessel I, Spang M, Besse M, Folsche T, Stephani C, Zilles D. Overlooking the obvious? Influence of electrolyte concentrations on seizure quality parameters in electroconvulsive therapy. Eur Arch Psychiatry Clin Neurosci 2020; 270:263-269. [PMID: 31317265 DOI: 10.1007/s00406-019-01046-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/12/2019] [Indexed: 01/12/2023]
Abstract
Clinical response to electroconvulsive therapy (ECT) depends on eliciting a generalized seizure. Though there are multiple ictal and other parameters to assess seizure quality, factors that influence these parameters have only been identified to a limited extend in antecedent studies (e.g., stimulus dosage, age). In the context of ECT, electrolyte concentrations have hardly been investigated so far-although hyponatremia is one well-known clinical factor to increase the risk of spontaneous seizures. In 31 patients with unipolar or bipolar depressive disorder, blood concentrations of sodium (Na), potassium (K), and calcium (Ca) were measured immediately prior to repeated sessions of maintenance ECT. Generalized linear mixed models were used to analyze the influence of Na, K, and Ca on seven seizure quality parameters: postictal suppression index (PSI), maximum sustained coherence (MSC), midictal amplitude, average seizure energy index, seizure duration (EEG/motor), and peak heart rate. Results show a statistically significant relationship between the serum sodium level and MSC: in the model, a reduction of 1 mmol/l led to an increase in interhemispheric coherence of 0.678%. The further markers remained unaffected by changes in electrolyte concentrations. This finding provides first evidence that a lower blood concentration of sodium could enhance the quality of ECT-induced seizures in terms of higher interhemispheric coherence.
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Affiliation(s)
- Michael Belz
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, von-Siebold-Strasse 5, 37075, Göttingen, Germany
| | - Isabel Methfessel
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, von-Siebold-Strasse 5, 37075, Göttingen, Germany
| | - Miriam Spang
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, von-Siebold-Strasse 5, 37075, Göttingen, Germany
| | - Matthias Besse
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, von-Siebold-Strasse 5, 37075, Göttingen, Germany
| | - Thorsten Folsche
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, von-Siebold-Strasse 5, 37075, Göttingen, Germany
| | - Caspar Stephani
- Department of Clinical Neurophysiology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
| | - David Zilles
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, von-Siebold-Strasse 5, 37075, Göttingen, Germany.
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Abstract
BACKGROUND Electroconvulsive therapy (ECT) is one of the most effective treatments for major depressive disorder (MDD), especially in cases of treatment-resistant MDD. Because of their pharmacological profiles, benzodiazepines (BZDs) are suspected to decrease the efficacy of ECT. This study investigated the effect of BZDs on ECT-induced clinical outcomes and ECT course parameters in patients with MDD. METHOD The impact of BZDs on severity of depression (Montgomery-Asberg Depression Rating Scale scores) and on ECT course parameters (seizure threshold, clinical and electroencephalographic seizure duration) was investigated in 70 patients with MDD who received an ECT course using dose-titration method (22 received concomitant BZDs). RESULTS Lower remission rates (52.0%) and smaller decreases in Montgomery-Asberg Depression Rating Scale scores were observed in the non-BZD group than in the BZD group (81.2%, P = 0.02). There were no significant differences between the 2 groups regarding seizure duration and seizure threshold. LIMITATIONS This was a retrospective study. Impact of BZDs on anxiety and cognition was not assessed. CONCLUSIONS Benzodiazepines increased the clinical efficacy of ECT when delivered using dose-titration method and bitemporal stimulation. Further studied are needed to understand the interaction between BZDs and ECT on clinical outcomes.
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Jeong SH, Youn T, Lee Y, Jang JH, Jeong YW, Kim YS, Chung IW. Initial Seizure Threshold in Brief-Pulse Bilateral Electroconvulsive Therapy in Patients with Schizophrenia or Schizoaffective Disorder. Psychiatry Investig 2019; 16:704-712. [PMID: 31429220 PMCID: PMC6761792 DOI: 10.30773/pi.2019.06.20.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/20/2019] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The present study aimed to report the initial seizure threshold (IST) of a brief-pulse bilateral electroconvulsive therapy (BP-BL ECT) in Korean patients with schizophrenia/schizoaffective disorder and to identify IST predictors. METHODS Among 67 patients who received ECT and diagnosed with schizophrenia/schizoaffective disorder based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, we included 56 patients who received 1-millisecond BP-BL ECT after anesthesia with sodium thiopental between March 2012 and June 2018. Demographic and clinical information was gathered from electronic medical records, and a multiple regression analysis was conducted to identify predictors of the IST. RESULTS The mean age of the patients was 36.9±12.0 years and 30 (53.6%) patients were male. The mean and median IST were 105.9±54.5 and 96 millicoulombs (mC), respectively. The IST was predicted by age, gender, and dose (mg/kg) of sodium thiopental. Other physical and clinical variables were not associated with the IST. CONCLUSION The present study demonstrated that the IST of 1-ms BP-BL ECT following sodium thiopental anesthesia in Korean patients was comparable to those reported in previous literature. The IST was associated with age, gender, and dose of sodium thiopental.
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Affiliation(s)
- Seong Hoon Jeong
- Department of Psychiatry, Eulji University Hospital, Daejeon, Republic of Korea
| | - Tak Youn
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea.,Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Younsuk Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Jin Hyeok Jang
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Young Wook Jeong
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Yong Sik Kim
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea.,Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - In Won Chung
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea.,Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
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Delamarre L, Galvao F, Gohier B, Poulet E, Brunelin J. Benzodiazepines enhance efficacy of electroconvulsive therapy in depression. Encephale 2019. [DOI: 10.1016/j.encep.2019.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wang YC, Lin HT, Lu ML, Huang MC, Chen CH, Wu TH, Wang S, Mao WC, Kuo PH, Chen HC. The Association Between the Sedative Loads and Clinical Severity Indicators in the First-Onset Major Depressive Disorder. Front Psychiatry 2019; 10:129. [PMID: 30936841 PMCID: PMC6431631 DOI: 10.3389/fpsyt.2019.00129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/22/2019] [Indexed: 12/15/2022] Open
Abstract
Background: High sedative use in a major depressive episode may imply specific clinical features. This study aims to examine the correlation between sedative use and clinical severity indicators in the initial treatment phase of first-onset major depressive disorder. Methods: A study cohort in the first episode of major depressive disorder was used to conduct pharmacological dissection. All participants had at least a 2-year follow-up period with a complete treatment record. The defined daily dose of antidepressants and augmentation agents were calculated as the antidepressant load and augmentation load, respectively. Sedative use, which was calculated as the equivalent dosage of lorazepam, were defined as the sedative load. These psychotropic loads were measured monthly and the averaged psychotropic loads for each day were obtained. Results: A total of 106 individuals (75.5% female) were included. The mean duration of disease course in participants was 5.5 ± 3.5 years. In the multiple regression analysis, after controlling for other classes of psychotropics and comorbid anxiety disorders, the sedative load independently correlated with higher number of antidepressants used, higher number of antidepressant used with an adequate dose and duration, more psychiatric emergency and outpatient visits within 2 years of disease onset. Conclusion: High loading of sedatives correlated with several indicators of clinical severity in major depressive disorder. The sedative load may be used as a specifier to identify subgroups in patients with major depressive disorder.
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Affiliation(s)
- Yen-Chin Wang
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Hai-Ti Lin
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Mong-Liang Lu
- Department of Psychiatry, Wan-Fang Hospital & School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ming-Chyi Huang
- Department of Psychiatry, Taipei City Hospital, Songde Branch, Taipei, Taiwan
| | - Chun-Hsin Chen
- Department of Psychiatry, Wan-Fang Hospital & School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tzu-Hua Wu
- Department of Clinical Pharmacy, School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Sabrina Wang
- School of Medicine, Institute of Anatomy and Cell Biology, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Chung Mao
- Department of Psychiatry, Cheng-Hsin General Hospital & School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Po-Hsiu Kuo
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hsi-Chung Chen
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.,Center of Sleep Disorders, National Taiwan University Hospital, Taipei, Taiwan
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Should Benzodiazepines and Anticonvulsants Be Used During Electroconvulsive Therapy?: A Case Study and Literature Review. J ECT 2017; 33:237-242. [PMID: 28767528 DOI: 10.1097/yct.0000000000000441] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This study aims to investigate the clinical effects of benzodiazepines or anticonvulsant use during a course of electroconvulsive therapy (ECT). METHOD A case report study of a patient who received ECT with and without concomitant flurazepam and pregabalin is presented. The literature on the use of benzodiazepines and anticonvulsants during ECT is reviewed. RESULTS A woman with treatment resistant depression received a course of ECT while taking flurazepam and pregabalin, but seizures were of short duration and symptomatic improvement was minimal. After discontinuation of flurazepam and pregabalin, a course of right unilateral ultrabrief ECT was associated with adequate seizures and remission of depression and suicidal ideation. Our literature review suggests that benzodiazepines decrease seizure duration, but most evidence shows no association with increased seizure threshold. One prospective RCT and 3 large retrospective studies found that benzodiazepines compromise the efficacy of unilateral but not bilateral ECT. Regarding anticonvulsants, several studies had varied and contradictory results on their effect on seizure duration and seizure threshold. Of the 2 large retrospective studies and 3 RCTs, only 1 retrospective study showed that anticonvulsants decrease the efficacy of ECT. CONCLUSIONS Judicious assessment of all medications used in combination with ECT is recommended. Overall, published studies suggest that benzodiazepines and anticonvulsants impact the clinical outcomes of ECT less than what would be expected given their pharmacologic effects. However, there are significant gaps in the literature, including a lack of study on suprathreshold stimulation of right unilateral ECT and the possibility of a greater effect with higher medication doses.
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Bai S, Gálvez V, Dokos S, Martin D, Bikson M, Loo C. Computational models of Bitemporal, Bifrontal and Right Unilateral ECT predict differential stimulation of brain regions associated with efficacy and cognitive side effects. Eur Psychiatry 2017; 41:21-29. [PMID: 28049077 DOI: 10.1016/j.eurpsy.2016.09.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/21/2016] [Accepted: 09/24/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Extensive clinical research has shown that the efficacy and cognitive outcomes of electroconvulsive therapy (ECT) are determined, in part, by the type of electrode placement used. Bitemporal ECT (BT, stimulating electrodes placed bilaterally in the frontotemporal region) is the form of ECT with relatively potent clinical and cognitive side effects. However, the reasons for this are poorly understood. OBJECTIVE This study used computational modelling to examine regional differences in brain excitation between BT, Bifrontal (BF) and Right Unilateral (RUL) ECT, currently the most clinically-used ECT placements. Specifically, by comparing similarities and differences in current distribution patterns between BT ECT and the other two placements, the study aimed to create an explanatory model of critical brain sites that mediate antidepressant efficacy and sites associated with cognitive, particularly memory, adverse effects. METHODS High resolution finite element human head models were generated from MRI scans of three subjects. The models were used to compare differences in activation between the three ECT placements, using subtraction maps. RESULTS AND CONCLUSION In this exploratory study on three realistic head models, Bitemporal ECT resulted in greater direct stimulation of deep midline structures and also left temporal and inferior frontal regions. Interpreted in light of existing knowledge on depressive pathophysiology and cognitive neuroanatomy, it is suggested that the former sites are related to efficacy and the latter to cognitive deficits. We hereby propose an approach using binarised subtraction models that can be used to optimise, and even individualise, ECT therapies.
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Affiliation(s)
- S Bai
- Department of Electrical and Computer Engineering, Technische Universität München, 80333 München, Germany; Graduate School of Biomedical Engineering, Faculty of Engineering, University of New South Wales (UNSW), NSW 2052, Australia
| | - V Gálvez
- School of Psychiatry, UNSW, NSW 2052, Australia; Black Dog Institute, NSW 2031, Australia
| | - S Dokos
- Graduate School of Biomedical Engineering, Faculty of Engineering, University of New South Wales (UNSW), NSW 2052, Australia
| | - D Martin
- School of Psychiatry, UNSW, NSW 2052, Australia; Black Dog Institute, NSW 2031, Australia
| | - M Bikson
- Department of Biomedical Engineering, The City College of The City University of New York, New York, USA
| | - C Loo
- School of Psychiatry, UNSW, NSW 2052, Australia; Black Dog Institute, NSW 2031, Australia; Department of Psychiatry, St George Hospital, NSW 2217, Australia.
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Buj-Alvarez I, Pifarré J, Marco G, de Sousa-Duso M, Martínez M, López-Gómez J. ¿Puede tener un papel la mascarilla laríngea en la práctica de la terapia electroconvulsiva? Un estudio piloto. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2016; 9:203-209. [DOI: 10.1016/j.rpsm.2015.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 07/31/2015] [Accepted: 09/30/2015] [Indexed: 11/15/2022]
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Abstract
OBJECTIVES Electroconvulsive therapy (ECT) is the most effective therapy for patients with treatment-resistant depression; however, some patients do not respond or relapse in a short time. Electroconvulsive therapy stimulus parameters may be related to the outcome. We carried out a retrospective study review to investigate various ECT parameters in relation to the outcome, clinical variables, and pharmacological treatments. Our aim was to understand which factors could be considered putative seizure quality markers and which are relevant to clinical practice. METHODS Two physicians evaluated the seizure length, the postictal suppression index, the wave amplitude, tachycardia, and hemispheric brain wave synchronicity in a double-blind manner for 45 treatment-resistant depression patients receiving ECT. RESULTS The analysis showed a significant association between the outcome and the ECT seizure quality measured by the parameters (P = 9.9 × 10). Among patients with poor-quality seizures, 61.5% relapsed after approximately 1 month from the last ECT session. Particularly, there was an association between higher symptomatology decrease and higher quality of hemispheric brain wave synchronicity (P = 5.0 × 10), as well as a higher wave amplitude (P = 0.01). CONCLUSIONS Our results confirm that ECT seizure quality was strongly correlated with the decrease of depressive symptomatology.
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Nitturkar AR, Sinha P, Bagewadi VI, Thirthalli J. Effect of age and anticonvulsants on seizure threshold during bilateral electroconvulsive therapy with brief-pulse stimulus: A chart-based analysis. Indian J Psychiatry 2016; 58:190-7. [PMID: 27385853 PMCID: PMC4919964 DOI: 10.4103/0019-5545.183792] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Efficacy and adverse effects of electroconvulsive therapy (ECT) depend on the extent to which the electrical stimulus exceeds patients' seizure thresholds (STs). Titration method of estimating ST is recommended. Age and co-prescribed anticonvulsants (ACs) are known to affect ST. Literature on ST in bilateral ECT (BLECT) is sparse. OBJECTIVE To explore the clinical and demographic determinants of ST in a clinically representative sample of patients prescribed with BLECT. MATERIALS AND METHODS ECT records of 640 patients who received BLECT in 2011 in an academic psychiatric setting were studied. Demographic, clinical, pharmacological, and ECT details were analyzed. As per the standard practice, during the 1(st) ECT session, ST was determined by titration method, starting with 30 milli-Coulombs (mC) and increasing by 30 mC and thence in steps of 60 mC. Increase in ST over up to 6(th) session of ECT was noted. Receiver operating characteristic curve was used to find age cut-off with high specificity for ST ≥120 mC. The associations of ST and increase in ST with the age cut-off and other clinical factors were assessed using Chi-square test and logistic regression analysis. RESULTS The mean age was 30.98 years (+11.23 years) and mean ST at 1(st) ECT session was 130.36 mC (+51.96 mC). There was significantly high positive correlation (r = 0.37, P < 0.001) between age and ST. Cut-off age of 45 years had high specificity: Only 4.6% of those older than 45 years had ST <120 mC. Higher proportion of patients on AC had ST ≥120 mC. These associations were seen even after controlling for potential confounds of each other using logistic regression analysis. The results were similar for increase in ST over the course of ECT. Sex, diagnosis, use of antipsychotics, antidepressants, lithium, and benzodiazepines (BZPs) had no effect on ST or its increase. CONCLUSIONS For BLECT using brief-pulse stimulus, ST depends on age and use of AC. For patients above the age of 45 years, ST estimation may be started at 120 mC with least risk of using unduly higher stimulus. Other medications including BZPs have little influence on ST.
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Affiliation(s)
- Abhishek R Nitturkar
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, Virginia 22908, USA
| | - Preeti Sinha
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Virupakshappa I Bagewadi
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Jagadisha Thirthalli
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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