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Deng ZD, Robins PL, Regenold W, Rohde P, Dannhauer M, Lisanby SH. How electroconvulsive therapy works in the treatment of depression: is it the seizure, the electricity, or both? Neuropsychopharmacology 2024; 49:150-162. [PMID: 37488281 PMCID: PMC10700353 DOI: 10.1038/s41386-023-01677-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/27/2023] [Accepted: 07/14/2023] [Indexed: 07/26/2023]
Abstract
We have known for nearly a century that triggering seizures can treat serious mental illness, but what we do not know is why. Electroconvulsive Therapy (ECT) works faster and better than conventional pharmacological interventions; however, those benefits come with a burden of side effects, most notably memory loss. Disentangling the mechanisms by which ECT exerts rapid therapeutic benefit from the mechanisms driving adverse effects could enable the development of the next generation of seizure therapies that lack the downside of ECT. The latest research suggests that this goal may be attainable because modifications of ECT technique have already yielded improvements in cognitive outcomes without sacrificing efficacy. These modifications involve changes in how the electricity is administered (both where in the brain, and how much), which in turn impacts the characteristics of the resulting seizure. What we do not completely understand is whether it is the changes in the applied electricity, or in the resulting seizure, or both, that are responsible for improved safety. Answering this question may be key to developing the next generation of seizure therapies that lack these adverse side effects, and ushering in novel interventions that are better, faster, and safer than ECT.
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Affiliation(s)
- Zhi-De Deng
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - Pei L Robins
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - William Regenold
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - Paul Rohde
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - Moritz Dannhauer
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - Sarah H Lisanby
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, USA.
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Langroudi ME, Shams-Alizadeh N, Maroufi A, Rahmani K, Rahchamani M. Association between postictal suppression and the therapeutic effects of electroconvulsive therapy: A systematic review. Asia Pac Psychiatry 2023; 15:e12544. [PMID: 37587610 DOI: 10.1111/appy.12544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 06/20/2023] [Accepted: 08/01/2023] [Indexed: 08/18/2023]
Abstract
Electroconvulsive therapy (ECT) is an effective and safe medical treatment for patients with severe mood and neuropsychiatric disorders. Since the advent of ECT, extensive research has been performed to identify the predictive factors for response to ECT. In recent decades, postictal suppression on an electroencephalogram (EEG) has been considered a potential predictor of response to ECT. We aimed to investigate the direct association between postictal suppression and the therapeutic effects of ECT. In this systematic review, all articles in the field of the association between postictal suppression and the therapeutic effects of ECT published between 1990 and 2021 were identified. The full texts of these articles, which include clinical trials and retrospective and cross-sectional studies, are available in scholarly research databases and search engines, including PubMed, Google Scholar, OVID, Web of Science, and Scopus. Of all retrieved articles, eight studies, including four retrospective cohort articles and four clinical trials, met the inclusion criteria for further analyses. The findings of this study showed a significant association between postictal suppression and the therapeutic efficacy of ECT. Factors such as electrode placement, tachycardia, type of anesthetic agent, and EEG amplitude were also directly related to postictal suppression and the efficacy of ECT. Postictal suppression on EEG can be considered a predictor of response to ECT. To increase the effectiveness of treatment with ECT and increase postictal suppression, factors including electrode placement, tachycardia, type of anesthesia, and EEG amplitude should be considered, which highlights the need for further research.
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Affiliation(s)
- Mahdie Ershad Langroudi
- Department of Psychiatry, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Narges Shams-Alizadeh
- Department of Psychiatry, Neuroscience Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Azad Maroufi
- Neurosciences Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Khaled Rahmani
- Department of Epidemiology, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Maryam Rahchamani
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Kritzer MD, Peterchev AV, Camprodon JA. Electroconvulsive Therapy: Mechanisms of Action, Clinical Considerations, and Future Directions. Harv Rev Psychiatry 2023; 31:101-113. [PMID: 37171471 PMCID: PMC10198476 DOI: 10.1097/hrp.0000000000000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
LEARNING OBJECTIVES • Outline and discuss the fundamental physiologic, cellular, and molecular mechanisms of ECT to devise strategies to optimize therapeutic outcomes• Summarize the overview of ECT, its efficacy in treating depression, the known effects on cognition, evidence of mechanisms, and future directions. ABSTRACT Electroconvulsive therapy (ECT) is the most effective treatment for a variety of psychiatric illnesses, including treatment-resistant depression, bipolar depression, mania, catatonia, and clozapine-resistant schizophrenia. ECT is a medical and psychiatric procedure whereby electrical current is delivered to the brain under general anesthesia to induce a generalized seizure. ECT has evolved a great deal since the 1930s. Though it has been optimized for safety and to reduce adverse effects on cognition, issues persist. There is a need to understand fundamental physiologic, cellular, and molecular mechanisms of ECT to devise strategies to optimize therapeutic outcomes. Clinical trials that set out to adjust parameters, electrode placement, adjunctive medications, and patient selection are critical steps towards the goal of improving outcomes with ECT. This narrative review provides an overview of ECT, its efficacy in treating depression, its known effects on cognition, evidence of its mechanisms, and future directions.
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Affiliation(s)
- Michael D Kritzer
- From the Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA (Drs. Kritzer, Camprodon); Department of Psychiatry and Behavioral Sciences, Department of Biomedical Engineering, Department of Electrical and Computer Engineering, Department of Neurosurgery, Duke University, Durham, NC (Dr. Peterchev)
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Unal G, Poon C, FallahRad M, Thahsin M, Argyelan M, Bikson M. Quasi-static pipeline in electroconvulsive therapy computational modeling. Brain Stimul 2023; 16:607-618. [PMID: 36933652 PMCID: PMC10988926 DOI: 10.1016/j.brs.2023.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Computational models of current flow during Electroconvulsive Therapy (ECT) rely on the quasi-static assumption, yet tissue impedance during ECT may be frequency specific and change adaptively to local electric field intensity. OBJECTIVES We systematically consider the application of the quasi-static pipeline to ECT under conditions where 1) static impedance is measured before ECT and 2) during ECT when dynamic impedance is measured. We propose an update to ECT modeling accounting for frequency-dependent impedance. METHODS The frequency content on an ECT device output is analyzed. The ECT electrode-body impedance under low-current conditions is measured with an impedance analyzer. A framework for ECT modeling under quasi-static conditions based on a single device-specific frequency (e.g., 1 kHz) is proposed. RESULTS Impedance using ECT electrodes under low-current is frequency dependent and subject specific, and can be approximated at >100 Hz with a subject-specific lumped parameter circuit model but at <100 Hz increased non-linearly. The ECT device uses a 2 μA 800 Hz test signal and reports a static impedance that approximate 1 kHz impedance. Combined with prior evidence suggesting that conductivity does not vary significantly across ECT output frequencies at high-currents (800-900 mA), we update the adaptive pipeline for ECT modeling centered at 1 kHz frequency. Based on individual MRI and adaptive skin properties, models match static impedance (at 2 μA) and dynamic impedance (at 900 mA) of four ECT subjects. CONCLUSIONS By considering ECT modeling at a single representative frequency, ECT adaptive and non-adaptive modeling can be rationalized under a quasi-static pipeline.
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Affiliation(s)
- Gozde Unal
- Department of Biomedical Engineering, The City College of New York, CUNY, New York, NY, USA.
| | - Cynthia Poon
- Department of Biomedical Engineering, The City College of New York, CUNY, New York, NY, USA
| | - Mohamad FallahRad
- Department of Biomedical Engineering, The City College of New York, CUNY, New York, NY, USA
| | - Myesha Thahsin
- Department of Biomedical Engineering, The City College of New York, CUNY, New York, NY, USA
| | - Miklos Argyelan
- Center for Neurosciences, The Feinstein Institute for Medical Research, North Shore- Long Island Jewish Health System, Manhasset, NY, 11030, USA
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York, CUNY, New York, NY, USA.
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Leaver AM, Espinoza R, Wade B, Narr KL. Parsing the Network Mechanisms of Electroconvulsive Therapy. Biol Psychiatry 2022; 92:193-203. [PMID: 35120710 PMCID: PMC9196257 DOI: 10.1016/j.biopsych.2021.11.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/03/2021] [Accepted: 11/19/2021] [Indexed: 12/17/2022]
Abstract
Electroconvulsive therapy (ECT) is one of the oldest and most effective forms of neurostimulation, wherein electrical current is used to elicit brief, generalized seizures under general anesthesia. When electrodes are positioned to target frontotemporal cortex, ECT is arguably the most effective treatment for severe major depression, with response rates and times superior to other available antidepressant therapies. Neuroimaging research has been pivotal in improving the field's mechanistic understanding of ECT, with a growing number of magnetic resonance imaging studies demonstrating hippocampal plasticity after ECT, in line with evidence of upregulated neurotrophic processes in the hippocampus in animal models. However, the precise roles of the hippocampus and other brain regions in antidepressant response to ECT remain unclear. Seizure physiology may also play a role in antidepressant response to ECT, as indicated by early positron emission tomography, single-photon emission computed tomography, and electroencephalography research and corroborated by recent magnetic resonance imaging studies. In this review, we discuss the evidence supporting neuroplasticity in the hippocampus and other brain regions during and after ECT, and their associations with antidepressant response. We also offer a mechanistic, circuit-level model that proposes that core mechanisms of antidepressant response to ECT involve thalamocortical and cerebellar networks that are active during seizure generalization and termination over repeated ECT sessions, and their interactions with corticolimbic circuits that are dysfunctional prior to treatment and targeted with the electrical stimulus.
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Affiliation(s)
- Amber M Leaver
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Evanston, Illinois.
| | - Randall Espinoza
- Department of Psychiatry and Behavioral Sciences, Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Benjamin Wade
- Department of Neurology, Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Katherine L Narr
- Department of Neurology, Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Department of Psychiatry and Behavioral Sciences, Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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Regenold WT, Deng ZD, Lisanby SH. Noninvasive neuromodulation of the prefrontal cortex in mental health disorders. Neuropsychopharmacology 2022; 47:361-372. [PMID: 34272471 PMCID: PMC8617166 DOI: 10.1038/s41386-021-01094-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/22/2021] [Accepted: 06/29/2021] [Indexed: 02/06/2023]
Abstract
More than any other brain region, the prefrontal cortex (PFC) gives rise to the singularity of human experience. It is therefore frequently implicated in the most distinctly human of all disorders, those of mental health. Noninvasive neuromodulation, including electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS) among others, can-unlike pharmacotherapy-directly target the PFC and its neural circuits. Direct targeting enables significantly greater on-target therapeutic effects compared with off-target adverse effects. In contrast to invasive neuromodulation approaches, such as deep-brain stimulation (DBS), noninvasive neuromodulation can reversibly modulate neural activity from outside the scalp. This combination of direct targeting and reversibility enables noninvasive neuromodulation to iteratively change activity in the PFC and its neural circuits to reveal causal mechanisms of both disease processes and healthy function. When coupled with neuronavigation and neurophysiological readouts, noninvasive neuromodulation holds promise for personalizing PFC neuromodulation to relieve symptoms of mental health disorders by optimizing the function of the PFC and its neural circuits. ClinicalTrials.gov Identifier: NCT03191058.
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Affiliation(s)
- William T. Regenold
- grid.416868.50000 0004 0464 0574Noninvasive Neuromodulation Unit, Experimental Therapeutics & Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD USA
| | - Zhi-De Deng
- grid.416868.50000 0004 0464 0574Noninvasive Neuromodulation Unit, Experimental Therapeutics & Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD USA
| | - Sarah H. Lisanby
- grid.416868.50000 0004 0464 0574Noninvasive Neuromodulation Unit, Experimental Therapeutics & Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD USA
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Di Iorio R, Rossi S, Rossini PM. One century of healing currents into the brain from the scalp: From electroconvulsive therapy to repetitive transcranial magnetic stimulation for neuropsychiatric disorders. Clin Neurophysiol 2021; 133:145-151. [PMID: 34864511 DOI: 10.1016/j.clinph.2021.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/01/2021] [Accepted: 10/30/2021] [Indexed: 11/27/2022]
Abstract
Electroconvulsive therapy (ECT) was applied for the first time in humans in 1938: after 80 years, it remains conceptually similar today except for modifications of the original protocol aimed to reduce adverse effects (as persistent memory deficits) without losing clinical efficacy. We illustrate the stages of development as well as ups and downs of ECT use in the last eighty years, and the impact that it still maintains for treatment of certain psychiatric conditions. Targeted, individualized and safe noninvasive neuromodulatory interventions are now possible for many neuropsychiatric disorders thanks to repetitive transcranial magnetic stimulation (rTMS) that injects currents in the brain through electromagnetic induction, powerful enough to depolarize cortical neurons and related networks. Although ECT and rTMS differ in basic concepts, mechanisms, tolerability, side effects and acceptability, and beyond their conceptual remoteness (ECT) or proximity (rTMS) to "precision medicine" approaches, the two brain stimulation techniques may be considered as complementary rather than competing in the current treatment of certain neuropsychiatric disorders.
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Affiliation(s)
- Riccardo Di Iorio
- Neurology Unit, Policlinic A. Gemelli Foundation IRCCS, Rome, Italy.
| | - Simone Rossi
- Siena Brain Investigation and Neuromodulation Lab (Si-BIN Lab), Department of Medicine, Surgery and Neuroscience, Section of Neurology and Clinical Neurophysiology, Policlinico Le Scotte, University of Siena, Italy
| | - Paolo M Rossini
- Department of Neuroscience & Neurorehabilitation, IRCCS San Raffaele-Pisana, Rome, Italy
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Wilkinson ST, Kitay BM, Harper A, Rhee TG, Sint K, Ghosh A, Lopez MO, Saenz S, Tsai J. Barriers to the Implementation of Electroconvulsive Therapy (ECT): Results From a Nationwide Survey of ECT Practitioners. Psychiatr Serv 2021; 72:752-757. [PMID: 33971727 DOI: 10.1176/appi.ps.202000387] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) is an effective treatment for major depressive disorder; yet, its use is confined to <1% of individuals with this disorder. The authors aimed to examine barriers to ECT from the perspective of the provider. METHODS Qualitative interviews were conducted with U.S.-based ECT providers to identify potential barriers. A quantitative survey was created asking providers to rank-order barriers to starting a new ECT service or expanding existing services. RESULTS Survey responses were received from 192 physicians. Respondents were representative of all ECT providers found in the Medicare Provider Utilization and Payment Database with respect to gender and geographic distribution. Approximately one-third (N=58, 30%) of survey respondents graduated from one of 12 residency programs. Programs with dedicated hospital space were more likely to have larger services than those borrowing surgical recovery space (χ2=25.87, df=1, p<0.001). The most prominent provider-reported barriers to expanding an existing ECT service were lack of physical space, stigma on the part of patients, and transportation difficulties. The most prominent barriers to initiating a new service were lack of well-trained colleagues and ECT practitioners, lack of a champion within the institution, and lack of physical space. Wide geographic variation was found in the availability of ECT, with the highest concentration of ECT providers per 1 million individuals found in New England (6.4), and the lowest found in the West South Central (1.1). CONCLUSIONS Coordinated efforts to overcome identified barriers may allow ECT to be more broadly implemented. Investments in education may increase the number of competent practitioners.
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Affiliation(s)
- Samuel T Wilkinson
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Brandon M Kitay
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Annie Harper
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Taeho Greg Rhee
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Kyaw Sint
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Ahana Ghosh
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Mayra Ortiz Lopez
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Sabina Saenz
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Jack Tsai
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
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Sidhom E, Omar MH. The Nomenclature of Electroconvulsive Therapy. J ECT 2021; 37:128-132. [PMID: 33337650 DOI: 10.1097/yct.0000000000000735] [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: 11/25/2022]
Abstract
ABSTRACT Electroconvulsive therapy (ECT) is an established but stigmatized psychiatric treatment. The term ECT reflects the treatment's modality and action. Several authors proposed different names for ECT to deal with stigma; however, available literature that promoted different names did not address the risk/benefit ratio or offer evidence-based approach to the efficacy of this approach. We aim to examine proposed names for their specificity, accuracy, understandability, and popularity. In addition, we aim to find evidence-based methods to combat the ECT-related stigma. We reviewed the literature relating to the proposed names using snowballing technique for literature search. Known ECT alternative names were used for search, and whenever another name appears, it was added to our search list. We conducted Medline, PsycINFO, Google Scholar, and PubMed search to check for popularity and cross examine whether proposed terms refer back to ECT. We searched for ECT and stigma, to find evidence for methods to tackle ECT-related stigma. Once, the search stopped yielding newer ideas, we stopped the search at a point of saturation, where no more ideas where generated. Our name search yielded 14 terms. Nine names avoided "electricity" and "convulsion," because of perceived associated stigma. Presence of different terminology can affect the clarity of patient-doctor communication, with no evidence of added benefit. Alternative names may affect doctor-doctor communication about this treatment. We concluded that it is safer to retain the term ECT for the sake of consistency and clarity of communication. Education and experience are evidence-based effective methods of tackling ECT-related stigma.
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Affiliation(s)
- Emad Sidhom
- From the Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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Sahlem GL, McCall WV, Short EB, Rosenquist PB, Fox JB, Youssef NA, Manett AJ, Kerns SE, Dancy MM, McCloud L, George MS, Sackeim HA. A two-site, open-label, non-randomized trial comparing Focal Electrically-Administered Seizure Therapy (FEAST) and right unilateral ultrabrief pulse electroconvulsive therapy (RUL-UBP ECT). Brain Stimul 2020; 13:1416-1425. [PMID: 32735987 PMCID: PMC7500956 DOI: 10.1016/j.brs.2020.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Focal Electrically-Administered Seizure Therapy (FEAST) is a form of electroconvulsive therapy (ECT) that spatially focuses the electrical stimulus to initiate seizure activity in right prefrontal cortex. Two open-label non-comparative studies suggested that FEAST has reduced cognitive side effects when compared to historical data from other forms of ECT. In two different ECT clinics, we compared the efficacy and cognitive side effects of FEAST and Right Unilateral Ultrabrief Pulse (RUL-UBP) ECT. METHODS Using a non-randomized, open-label design, 39 depressed adults were recruited after referral for ECT. Twenty patients received FEAST (14 women; age 45.2 ± 12.7), and 19 received RUL-UBP ECT (16 women; age 43.2 ± 16.4). Key cognitive outcome measures were the postictal time to reorientation and the Columbia University Autobiographical Memory Interview: Short-Form (CUAMI-SF). Antidepressant effects were assessed using the Hamilton Rating Scale for Depression (HRSD24). RESULTS In the Intent-to-treat sample, a repeated measures mixed model suggested no between group difference in HRSD24 score over time (F1,35 = 0.82, p = 0.37), while the response rate favored FEAST (FEAST: 65%; RUL-UBP ECT: 57.9%), and the remission rate favored RUL-UBP ECT (FEAST: 35%; RUL-UBP ECT: 47.4%). The FEAST group had numeric superiority in average time to reorientation (FEAST: 6.6 ± 5.0 min; RUL-UBP ECT: 8.8 ± 5.8 min; Cohens d = 0.41), and CUAMI-SF consistency score (FEAST: 69.2 ± 14.2%; RUL-UBP ECT: 63.9 ± 9.9%; Cohens d = 0.43); findings that failed to meet statistical significance. CONCLUSIONS FEAST exerts similar efficacy relative to an optimal form of conventional ECT and may have milder cognitive side effects. A blinded, randomized, non-inferiority trial is needed.
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Affiliation(s)
- Gregory L Sahlem
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA.
| | - William V McCall
- Department of Psychiatry and Health Behavior, GA, USA; Medical College of Georgia, GA, USA; Augusta University, GA, USA
| | - E Baron Short
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA
| | - Peter B Rosenquist
- Department of Psychiatry and Health Behavior, GA, USA; Medical College of Georgia, GA, USA; Augusta University, GA, USA
| | - James B Fox
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA
| | - Nagy A Youssef
- Department of Psychiatry and Health Behavior, GA, USA; Medical College of Georgia, GA, USA; Augusta University, GA, USA
| | - Andrew J Manett
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA
| | - Suzanne E Kerns
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA
| | - Morgan M Dancy
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA
| | - Laryssa McCloud
- Department of Psychiatry and Health Behavior, GA, USA; Medical College of Georgia, GA, USA; Augusta University, GA, USA
| | - Mark S George
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA; Ralph H. Johnson VA Medical Center, SC, USA
| | - Harold A Sackeim
- Departments of Psychiatry and Radiology, Columbia University, NY, USA
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Depressive Symptom Dimensions in Treatment-Resistant Major Depression and Their Modulation With Electroconvulsive Therapy. J ECT 2020; 36:123-129. [PMID: 31464814 PMCID: PMC7044066 DOI: 10.1097/yct.0000000000000623] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Symptom heterogeneity in major depressive disorder obscures diagnostic and treatment-responsive biomarker identification. Whether symptom constellations are differentially changed by electroconvulsive therapy (ECT) remains unknown. We investigate the clustering of depressive symptoms over the ECT index and whether ECT differentially influences symptom clusters. METHODS The 17-item Hamilton Depression Rating Scale (HDRS-17) was collected from 111 patients with current depressive episode before and after ECT from 4 independent participating sites of the Global ECT-MRI Research Collaboration. Exploratory factor analysis of HDRS-17 items pre- and post-ECT treatment identified depressive symptom dimensions before and after ECT. A 2-way analysis of covariance was used to determine whether baseline symptom clusters were differentially changed by ECT between treatment remitters (defined as patients with posttreatment HDRS-17 total score ≤8) and nonremitters while controlling for pulse width, titration method, concurrent antidepressant treatment, use of benzodiazepine, and demographic variables. RESULTS A 3-factor solution grouped pretreatment HDRS-17 items into core mood/anhedonia, somatic, and insomnia dimensions. A 2-factor solution best described the symptoms at posttreatment despite poorer separation of items. Among remitters, core mood/anhedonia symptoms were significantly more reduced than somatic and insomnia dimensions. No differences in symptom dimension trajectories were observed among nonremitting patients. CONCLUSIONS Electroconvulsive therapy targets the underlying source of depressive symptomatology and may confer differential degrees of improvement in certain core depressive symptoms. Our findings of differential trajectories of symptom clusters over the ECT index might help related predictive biomarker studies to refine their approaches by identifying predictors of change along each latent symptom dimension.
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12
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Liou JY, Smith EH, Bateman LM, Bruce SL, McKhann GM, Goodman RR, Emerson RG, Schevon CA, Abbott LF. A model for focal seizure onset, propagation, evolution, and progression. eLife 2020; 9:50927. [PMID: 32202494 PMCID: PMC7089769 DOI: 10.7554/elife.50927] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 03/04/2020] [Indexed: 12/16/2022] Open
Abstract
We developed a neural network model that can account for major elements common to human focal seizures. These include the tonic-clonic transition, slow advance of clinical semiology and corresponding seizure territory expansion, widespread EEG synchronization, and slowing of the ictal rhythm as the seizure approaches termination. These were reproduced by incorporating usage-dependent exhaustion of inhibition in an adaptive neural network that receives global feedback inhibition in addition to local recurrent projections. Our model proposes mechanisms that may underline common EEG seizure onset patterns and status epilepticus, and postulates a role for synaptic plasticity in the emergence of epileptic foci. Complex patterns of seizure activity and bi-stable seizure end-points arise when stochastic noise is included. With the rapid advancement of clinical and experimental tools, we believe that this model can provide a roadmap and potentially an in silico testbed for future explorations of seizure mechanisms and clinical therapies.
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Affiliation(s)
- Jyun-You Liou
- Department of Physiology and Cellular Biophysics, Columbia University, New York, United States.,Department of Anesthesiology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, United States.,Department of Neurology, Columbia University Medical Center, New York, United States
| | - Elliot H Smith
- Department of Neurological Surgery, Columbia University Medical Center, New York, United States
| | - Lisa M Bateman
- Department of Neurology, Columbia University Medical Center, New York, United States
| | - Samuel L Bruce
- Vagelos College of Physicians & Surgeons, Columbia University, New York, United States
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, New York, United States
| | - Robert R Goodman
- Department of Neurological Surgery, Columbia University Medical Center, New York, United States
| | - Ronald G Emerson
- Department of Neurology, Columbia University Medical Center, New York, United States
| | - Catherine A Schevon
- Department of Neurology, Columbia University Medical Center, New York, United States
| | - L F Abbott
- Department of Physiology and Cellular Biophysics, Columbia University, New York, United States.,Mortimer B. Zuckerman Mind Brain Behavior Institute, Department of Neuroscience, Columbia University, New York, United States
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13
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Computational comparison of conventional and novel electroconvulsive therapy electrode placements for the treatment of depression. Eur Psychiatry 2019; 60:71-78. [PMID: 31234010 DOI: 10.1016/j.eurpsy.2019.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/17/2019] [Accepted: 05/18/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is a highly effective treatment for severe psychiatric disorders. Despite its high efficacy, the use of ECT would be greater if the risk of cognitive side effects were reduced. Over the last 20 years, developments in ECT technique, including improvements in the dosing methodology and modification of the stimulus waveform, have allowed for improved treatment methods with reduced adverse cognitive effects. There is increasing evidence that the electrode placement is important for orienting the electrical stimulus and therefore modifying treatment outcomes, with potential for further improvement of the placements currently used in ECT. OBJECTIVE We used computational modelling to perform an in-depth examination into regional differences in brain excitation by the ECT stimulus for several lesser known and novel electrode placements, in order to investigate the potential for an electrode placement that may optimise clinical outcomes. METHODS High resolution finite element human head models were generated from MRI scans of three subjects. The models were used to compare regional differences in average electric field (EF) magnitude among a total of thirteen bipolar ECT electrode placements, i.e. three conventional placements as well as ten lesser known and novel placements. RESULTS AND CONCLUSION In this exploratory study on a systemic comparison of thirteen ECT electrode placements, the EF magnitude at regions of interest (ROIs) was highly dependent upon the position of both electrodes, especially the ROIs close to the cortical surface. Compared to conventional right-unilateral (RUL) ECT using a temporo-parietal placement, fronto-parietal and supraorbito-parietal RUL also robustly stimulated brain regions considered important for efficacy, while sparing regions related to cognitive functions, and may be a preferrable approach to the currently used placement for RUL ECT. The simulations also found that regional average EF magnitude varied between individual subjects, due to factors such as head size, and results also depended on the size of the defined ROI.
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Abbott CC, Miller J, Lloyd M, Tohen M. Electroconvulsive therapy electrode placement for bipolar state-related targeted engagement. Int J Bipolar Disord 2019; 7:11. [PMID: 31053985 PMCID: PMC6499851 DOI: 10.1186/s40345-019-0146-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/19/2019] [Indexed: 02/06/2023] Open
Abstract
Background Electroconvulsive therapy (ECT) is an effective treatment for all bipolar states. However, ECT remains underutilized, likely stemming from stigma and the risk of neurocognitive impairment. Neuroimaging research has identified state-specific areas of aberrant brain activity that may serve as targets for therapeutic brain stimulation. Electrode placement determines the geometry of the electric field and can be either non-focal (bitemporal) or more focal (right unilateral or bifrontal). Previous research has shown that electrode placement can impact clinical and cognitive outcomes independent of seizure activity. This review critically examines the evidence that focal (unilateral or bifrontal) electrode placements target specific aberrant circuitry in specific bipolar states to optimize clinical outcomes. We hypothesize that optimal target engagement for a bipolar state will be associated with equivalent efficacy relative to bitemporal non-focal stimulation with less neurocognitive impairment. Methods We performed a literature search in the PubMed database. Inclusion criteria included prospective, longitudinal investigations during the ECT series with specific electrode placements within a bipolar state from 2000 to 2018. Results We identified investigations that met our inclusion criteria with bipolar mania (n = 6), depression (n = 6), mixed (n = 3) and catatonia (n = 1) states. These studies included clinical outcomes and several included cognitive outcomes, which were discussed separately. Conclusions While the heterogeneity of the studies makes comparisons difficult, important patterns included the reduced cognitive side effects, faster rate of response, and equivalent efficacy rates of the focal electrode placements (right unilateral and bifrontal) when compared to non-focal (bitemporal) placement. Further avenues for research include more robust cognitive assessments to separate procedure-related and state-related impairment. In addition, future studies could investigate novel electrode configurations with more specific target engagement for different bipolar states.
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Affiliation(s)
- Christopher C Abbott
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, University of New Mexico School of Medicine, Albuquerque, NM, 87131, USA.
| | - Jeremy Miller
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, University of New Mexico School of Medicine, Albuquerque, NM, 87131, USA
| | - Megan Lloyd
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, University of New Mexico School of Medicine, Albuquerque, NM, 87131, USA
| | - Mauricio Tohen
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, University of New Mexico School of Medicine, Albuquerque, NM, 87131, USA
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Volume of the Human Hippocampus and Clinical Response Following Electroconvulsive Therapy. Biol Psychiatry 2018; 84:574-581. [PMID: 30006199 PMCID: PMC6697556 DOI: 10.1016/j.biopsych.2018.05.017] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/29/2018] [Accepted: 05/13/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Hippocampal enlargements are commonly reported after electroconvulsive therapy (ECT). To clarify mechanisms, we examined if ECT-induced hippocampal volume change relates to dose (number of ECT sessions and electrode placement) and acts as a biomarker of clinical outcome. METHODS Longitudinal neuroimaging and clinical data from 10 independent sites participating in the Global ECT-Magnetic Resonance Imaging Research Collaboration (GEMRIC) were obtained for mega-analysis. Hippocampal volumes were extracted from structural magnetic resonance images, acquired before and after patients (n = 281) experiencing a major depressive episode completed an ECT treatment series using right unilateral and bilateral stimulation. Untreated nondepressed control subjects (n = 95) were scanned twice. RESULTS The linear component of hippocampal volume change was 0.28% (SE 0.08) per ECT session (p < .001). Volume change varied by electrode placement in the left hippocampus (bilateral, 3.3 ± 2.2%, d = 1.5; right unilateral, 1.6 ± 2.1%, d = 0.8; p < .0001) but not the right hippocampus (bilateral, 3.0 ± 1.7%, d = 1.8; right unilateral, 2.7 ± 2.0%, d = 1.4; p = .36). Volume change for electrode placement per ECT session varied similarly by hemisphere. Individuals with greater treatment-related volume increases had poorer outcomes (Montgomery-Åsberg Depression Rating Scale change -1.0 [SE 0.35], per 1% volume increase, p = .005), although the effects were not significant after controlling for ECT number (slope -0.69 [SE 0.38], p = .069). CONCLUSIONS The number of ECT sessions and electrode placement impacts the extent and laterality of hippocampal enlargement, but volume change is not positively associated with clinical outcome. The results suggest that the high efficacy of ECT is not explained by hippocampal enlargement, which alone might not serve as a viable biomarker for treatment outcome.
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A Blind Module Identification Approach for Predicting Effective Connectivity Within Brain Dynamical Subnetworks. Brain Topogr 2018; 32:28-65. [PMID: 30076488 DOI: 10.1007/s10548-018-0666-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 07/28/2018] [Indexed: 10/28/2022]
Abstract
Model-based network discovery measures, such as the brain effective connectivity, require fitting of generative process models to measurements obtained from key areas across the network. For distributed dynamic phenomena, such as generalized seizures and slow-wave sleep, studying effective connectivity from real-time recordings is significantly complicated since (i) outputs from only a subnetwork can be practically measured, and (ii) exogenous subnetwork inputs are unobservable. Model fitting, therefore, constitutes a challenging blind module identification or model inversion problem for finding both the parameters and the many unknown inputs of the subnetwork. We herein propose a novel estimation framework for identifying nonlinear dynamic subnetworks in the case of slowly-varying, otherwise unknown local inputs. Starting with approximate predictions obtained using Cubature Kalman filtering, residuals of local output predictions are utilized to improve upon local input estimates. The algorithm performance is tested on both simulated and clinical EEG of induced seizures under electroconvulsive therapy (ECT). For the simulated network, the algorithm significantly boosted the estimation accuracy for inputs and connections from noisy EEG. For the clinical data, the algorithm predicted increased subnetwork inputs during the pre-stimulus anesthesia condition. Importantly, it predicted an increased frontocentral connectivity during the generalized seizure that is commensurate with electrode placement and that corroborates the clinical hypothesis of increased frontal focality of therapeutic ECT seizures. The proposed framework can be extended to account for several input configurations and can in principle be applied to study effective connectivity within brain subnetworks defined at the microscale (cortical lamina interaction) or at the macroscale (sensory integration).
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17
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Structural-functional brain changes in depressed patients during and after electroconvulsive therapy. Acta Neuropsychiatr 2018; 30:17-28. [PMID: 27876102 DOI: 10.1017/neu.2016.62] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Electroconvulsive therapy (ECT) is a non-pharmacological treatment that is effective in treating severe and treatment-resistant depression. Although the efficacy of ECT has been demonstrated to treat major depressive disorder (MDD), the brain mechanisms underlying this process remain unclear. Structural-functional changes occur with the use of ECT as a treatment for depression based on magnetic resonance imaging (MRI). For this reason, we have tried to identify the changes that were identified by MRI to try to clarify some operating mechanisms of ECT. We focus to brain changes on MRI [structural MRI (sMRI), functional MRI (fMRI) and diffusion tensor imging (DTI)] after ECT. METHODS A systematic search of the international literature was performed using the bibliographic search engines PubMed and Embase. The research focused on papers published up to 30 September 2015. The following Medical Subject Headings (MESH) terms were used: electroconvulsive therapy AND (MRI OR fMRI OR DTI). Papers published in English were included. Four authors searched the database using a predefined strategy to identify potentially eligible studies. RESULTS There were structural changes according to the sMRI performed before and after ECT treatment. These changes do not seem to be entirely due to oedema. This investigation assessed the functional network connectivity associated with the ECT response in MDD. ECT response reverses the relationship from negative to positive between the two pairs of networks. CONCLUSION We found structural-functional changes in MRI post-ECT. Because of the currently limited MRI data on ECT in the literature, it is necessary to conduct further investigations using other MRI technology.
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McDonald WM. Neuromodulation Treatments for Geriatric Mood and Cognitive Disorders. Am J Geriatr Psychiatry 2016; 24:1130-1141. [PMID: 27889282 DOI: 10.1016/j.jagp.2016.08.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/25/2016] [Accepted: 08/26/2016] [Indexed: 01/05/2023]
Abstract
There is increasing evidence for the efficacy of neuromodulation in the treatment of resistant mood disorders and emerging data supporting the use of neuromodulation in cognitive disorders. A significant minority of depressed elders do not respond to pharmacotherapy and/or psychotherapy. This has led clinicians to recommend the increasing use of electroconvulsive therapy (ECT) in the treatment of medication-resistant or life-threatening geriatric depression. Multiple studies have supported the safety and efficacy of ECT in the elderly, yet ECT is associated with side effects including cardiovascular and cognitive side effects. Neuromodulation therapies have the potential for providing effective treatment for treatment-resistant older adults with reduced side effects and this review will outline the risks and benefits of neuromodulation treatment in geriatric psychiatry. There is also emerging evidence of the efficacy of neuromodulation devices in the treatment of cognitive disorders. Pharmacotherapy has been largely ineffective in changing the course of neurodegenerative diseases causing dementia and other treatments are clearly needed. This review will outline the available evidence for neuromodulation in the treatment of mood and cognitive disorders in the elderly.
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Affiliation(s)
- William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA.
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19
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Expanded Safety and Efficacy Data for a New Method of Performing Electroconvulsive Therapy: Focal Electrically Administered Seizure Therapy. J ECT 2016; 32:197-203. [PMID: 27379790 PMCID: PMC5058644 DOI: 10.1097/yct.0000000000000328] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) is the most rapid and effective antidepressant treatment but with concerns about cognitive adverse effects. A new form of ECT, focal electrically administered seizure therapy (FEAST), was designed to increase the focality of stimulation and better match stimulus parameters with neurophysiology. We recently reported on the safety and feasibility of FEAST in a cohort (n = 17) of depressed patients. We now report on the safety, feasibility, preliminary efficacy, and cognitive effects of FEAST in a new cohort. METHODS Open-label FEAST was administered to 20 depressed adults (6 men; 3 with bipolar disorder; age 49.1 ± 10.6 years). Clinical and cognitive assessments were obtained at baseline and end of course. Time to orientation recovery was assessed at each treatment. Nonresponders switched to conventional ECT. RESULTS Participants tolerated the treatment well with no dropouts. Five patients (25%) transitioned from FEAST to conventional ECT due to inadequate response. After FEAST (mean, 9.3 ± 3.5 sessions; range, 4-14), there was a 58.1% ± 36.0% improvement in Hamilton Rating Scale for Depression scores compared with that in the baseline (P < 0.0001); 13 (65%) of 20 patients met response criteria, and 11 (55%) of 20 met remission criteria. Patients achieved reorientation (4 of 5 items) in 4.4 ± 3.0 minutes (median, 4.5 minutes), timed from eyes opening. There was no deterioration in neuropsychological measures. CONCLUSIONS These findings provide further support for the safety and efficacy of FEAST. The remission and response rates were in the range found using conventional ECT, and the time to reorientation may be quicker. However, without a randomized comparison group, conclusions are tentative.
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Ahmadi N, Moss L, Simon E, Nemeroff CB, Atre-Vaidya N. EFFICACY AND LONG-TERM CLINICAL OUTCOME OF COMORBID POSTTRAUMATIC STRESS DISORDER AND MAJOR DEPRESSIVE DISORDER AFTER ELECTROCONVULSIVE THERAPY. Depress Anxiety 2016; 33:640-7. [PMID: 26555786 DOI: 10.1002/da.22451] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 10/01/2015] [Accepted: 10/04/2015] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Many patients fulfill criteria for both posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Electroconvulsive therapy (ECT) is generally acknowledged to be the most-effective treatment for refractory MDD. This study investigated the efficacy of ECT on long-term clinical outcome of comorbid PTSD and MDD. METHODS This retrospective nested matched case-control study is inclusive of 22,164 subjects [3,485 with comorbid MDD and PTSD (92 with ECT and 3,393 without ECT) and 18,679 without MDD and PTSD]. RESULTS Using the clinical global impression scale (CGI) to assess efficacy, more-robust improvement of PTSD and MDD symptoms was observed with ECT (90%), compared to antidepressant-treatment alone(50%) (P = 0.001). During the median of 8 years of follow-up, the death-rate was 8% in subjects without PTSD and MDD, 9.7% in PTSD and MDD treated with ECT and 18% in PTSD and MDD without ECT (P < 0.05). The suicide-rate was 2.2 and 5.9% in PTSD and MDD with and without ECT-treatment, respectively (P < 0.05). Survival-analyses revealed that the relative-risk of cardiovascular and all-cause mortality is not significantly different in patients with comorbid MDD and PTSD treated with ECT, compared to a matched-cohort without PTSD and MDD (P > 0.05). The relative risk of suicidality, all-cause, and cardiovascular mortality was reduced 64, 65, and 46% in MDD and PTSD patients treated with ECT, compared to those without ECT (P < 0.05). CONCLUSION ECT is associated with a significant reduction of symptoms of PTSD and MDD, as well as reduction in risk of suicidality, cardiovascular, and all-cause mortality in MDD and PTSD, an effect more robust than antidepressant-therapy alone.
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Affiliation(s)
- Naser Ahmadi
- Captain James A Lovell Federal Healthcare Center, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Lori Moss
- Captain James A Lovell Federal Healthcare Center, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Edwin Simon
- Captain James A Lovell Federal Healthcare Center, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Charles B Nemeroff
- Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Nutan Atre-Vaidya
- Captain James A Lovell Federal Healthcare Center, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
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Lee WH, Lisanby SH, Laine AF, Peterchev AV. Comparison of electric field strength and spatial distribution of electroconvulsive therapy and magnetic seizure therapy in a realistic human head model. Eur Psychiatry 2016; 36:55-64. [PMID: 27318858 DOI: 10.1016/j.eurpsy.2016.03.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 03/04/2016] [Accepted: 03/06/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND This study examines the strength and spatial distribution of the electric field induced in the brain by electroconvulsive therapy (ECT) and magnetic seizure therapy (MST). METHODS The electric field induced by standard (bilateral, right unilateral, and bifrontal) and experimental (focal electrically administered seizure therapy and frontomedial) ECT electrode configurations as well as a circular MST coil configuration was simulated in an anatomically realistic finite element model of the human head. Maps of the electric field strength relative to an estimated neural activation threshold were used to evaluate the stimulation strength and focality in specific brain regions of interest for these ECT and MST paradigms and various stimulus current amplitudes. RESULTS The standard ECT configurations and current amplitude of 800-900mA produced the strongest overall stimulation with median of 1.8-2.9 times neural activation threshold and more than 94% of the brain volume stimulated at suprathreshold level. All standard ECT electrode placements exposed the hippocampi to suprathreshold electric field, although there were differences across modalities with bilateral and right unilateral producing respectively the strongest and weakest hippocampal stimulation. MST stimulation is up to 9 times weaker compared to conventional ECT, resulting in direct activation of only 21% of the brain. Reducing the stimulus current amplitude can make ECT as focal as MST. CONCLUSIONS The relative differences in electric field strength may be a contributing factor for the cognitive sparing observed with right unilateral compared to bilateral ECT, and MST compared to right unilateral ECT. These simulations could help understand the mechanisms of seizure therapies and develop interventions with superior risk/benefit ratio.
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Affiliation(s)
- W H Lee
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - S H Lisanby
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27710, USA; Department of Psychology & Neuroscience, Duke University, Durham, NC 27708, USA; Department of Psychiatry, Columbia University, New York, NY 10032, USA; National Institute of Mental Health, National Institutes of Health, Bethesda, MD 20892, USA
| | - A F Laine
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
| | - A V Peterchev
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27710, USA; Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA; Department of Electrical and Computer Engineering, Duke University, Durham, NC 27708, USA.
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Advances in the Application of Electroconvulsive Therapy. Curr Behav Neurosci Rep 2016. [DOI: 10.1007/s40473-016-0074-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Peterchev AV, Krystal AD, Rosa MA, Lisanby SH. Individualized Low-Amplitude Seizure Therapy: Minimizing Current for Electroconvulsive Therapy and Magnetic Seizure Therapy. Neuropsychopharmacology 2015; 40:2076-84. [PMID: 25920013 PMCID: PMC4613599 DOI: 10.1038/npp.2015.122] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 03/31/2015] [Accepted: 04/24/2015] [Indexed: 11/09/2022]
Abstract
Electroconvulsive therapy (ECT) at conventional current amplitudes (800-900 mA) is highly effective but carries the risk of cognitive side effects. Lowering and individualizing the current amplitude may reduce side effects by virtue of a less intense and more focal electric field exposure in the brain, but this aspect of ECT dosing is largely unexplored. Magnetic seizure therapy (MST) induces a weaker and more focal electric field than ECT; however, the pulse amplitude is not individualized and the minimum amplitude required to induce a seizure is unknown. We titrated the amplitude of long stimulus trains (500 pulses) as a means of determining the minimum current amplitude required to induce a seizure with ECT (bilateral, right unilateral, bifrontal, and frontomedial electrode placements) and MST (round coil on vertex) in nonhuman primates. Furthermore, we investigated a novel method of predicting this amplitude-titrated seizure threshold (ST) by a non-convulsive measurement of motor threshold (MT) using single pulses delivered through the ECT electrodes or MST coil. Average STs were substantially lower than conventional pulse amplitudes (112-174 mA for ECT and 37.4% of maximum device amplitude for MST). ST was more variable in ECT than in MST. MT explained 63% of the ST variance and is hence the strongest known predictor of ST. These results indicate that seizures can be induced with less intense electric fields than conventional ECT that may be safer; efficacy and side effects should be evaluated in clinical studies. MT measurement could be a faster and safer alternative to empirical ST titration for ECT and MST.
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Affiliation(s)
- Angel V Peterchev
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, USA
| | - Andrew D Krystal
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Moacyr A Rosa
- Institute for Advanced Research in Neurostimulation, São Paulo, Brazil
| | - Sarah H Lisanby
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Department of Psychology and Neuroscience, Duke University, Durham, NC, USA
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25
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Weiner RD. Introduction to Convulsive Therapy. Brain Stimul 2015. [DOI: 10.1002/9781118568323.ch5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Lee WH, Lisanby SH, Laine AF, Peterchev AV. Electric Field Model of Transcranial Electric Stimulation in Nonhuman Primates: Correspondence to Individual Motor Threshold. IEEE Trans Biomed Eng 2015; 62:2095-105. [PMID: 25910001 DOI: 10.1109/tbme.2015.2425406] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To develop a pipeline for realistic head models of nonhuman primates (NHPs) for simulations of noninvasive brain stimulation, and use these models together with empirical threshold measurements to demonstrate that the models capture individual anatomical variability. METHODS Based on structural MRI data, we created models of the electric field (E-field) induced by right unilateral (RUL) electroconvulsive therapy (ECT) in four rhesus macaques. Individual motor threshold (MT) was measured with transcranial electric stimulation (TES) administered through the RUL electrodes in the same subjects. RESULTS The interindividual anatomical differences resulted in 57% variation in median E-field strength in the brain at fixed stimulus current amplitude. Individualization of the stimulus current by MT reduced the E-field variation in the target motor area by 27%. There was significant correlation between the measured MT and the ratio of simulated electrode current and E-field strength (r(2) = 0.95, p = 0.026). Exploratory analysis revealed significant correlations of this ratio with anatomical parameters including of the superior electrode-to-cortex distance, vertex-to-cortex distance, and brain volume (r(2) > 0.96, p < 0.02). The neural activation threshold was estimated to be 0.45 ±0.07 V/cm for 0.2-ms stimulus pulse width. CONCLUSION These results suggest that our individual-specific NHP E-field models appropriately capture individual anatomical variability relevant to the dosing of TES/ECT. These findings are exploratory due to the small number of subjects. SIGNIFICANCE This study can contribute insight in NHP studies of ECT and other brain stimulation interventions, help link the results to clinical studies, and ultimately lead to more rational brain stimulation dosing paradigms.
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Neuromodulation for depression: invasive and noninvasive (deep brain stimulation, transcranial magnetic stimulation, trigeminal nerve stimulation). Neurosurg Clin N Am 2014; 25:103-16. [PMID: 24262903 DOI: 10.1016/j.nec.2013.10.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Major depressive disorder is among the most disabling illnesses and, despite best practices with medication and psychotherapy, many patients remain ill even after several treatment trials. For many of these patients with treatment-resistant or pharmacoresistant depression, treatment with neuromodulation offers an alternative. Options range from systems that are implanted to others that are entirely noninvasive. This review surveys recent literature to update readers on 3 particular interventions: deep brain stimulation, transcranial magnetic stimulation, and trigeminal nerve stimulation. Additional comparative research is needed to delineate the relative advantages of these treatments, and how best to match individual patients to neuromodulation intervention.
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Abstract
For many patients with neuropsychiatric illnesses, standard psychiatric treatments with mono or combination pharmacotherapy, psychotherapy, and transcranial magnetic stimulation are ineffective. For these patients with treatment-resistant neuropsychiatric illnesses, a main therapeutic option is electroconvulsive therapy (ECT). Decades of research have found ECT to be highly effective; however, it can also result in adverse neurocognitive effects. Specifically, ECT results in disorientation after each session, anterograde amnesia for recently learned information, and retrograde amnesia for previously learned information. Unfortunately, the neurocognitive effects and underlying mechanisms of action of ECT remain poorly understood. The purpose of this paper was to synthesize the multiple moderating and mediating factors that are thought to underlie the neurocognitive effects of ECT into a coherent model. Such factors include demographic and neuropsychological characteristics, neuropsychiatric symptoms, ECT technical parameters, and ECT-associated neurophysiological changes. Future research is warranted to evaluate and test this model, so that these findings may support the development of more refined clinical seizure therapy delivery approaches and efficacious cognitive remediation strategies to improve the use of this important and widely used intervention tool for neuropsychiatric diseases.
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Chahine G, Short B, Spicer K, Schmidt M, Burns C, Atoui M, George MS, Sackeim HA, Nahas Z. Regional Cerebral Blood Flow Changes Associated With Focal Electrically Administered Seizure Therapy (FEAST). Brain Stimul 2014; 7:483-5. [DOI: 10.1016/j.brs.2014.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 02/17/2014] [Accepted: 02/18/2014] [Indexed: 11/28/2022] Open
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Prabhu S, Piallat B, Devergnas A, Blauwblomme T, Sherdil A, Chivoret N, David O, Chabardès S. Characteristics of a primate model of focal motor cortical seizures suitable for preclinical testing of therapies like DBS. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/wjns.2014.41006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Riva-Posse P, Hermida AP, McDonald WM. The role of electroconvulsive and neuromodulation therapies in the treatment of geriatric depression. Psychiatr Clin North Am 2013; 36:607-30. [PMID: 24229660 DOI: 10.1016/j.psc.2013.08.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Geriatric depression is associated with increased mortality because of suicide and decreases in functional and physical health. Many elders' depression is resistant to psychotherapy and medication and can become chronic. Electroconvulsive therapy (ECT) is increasingly used in the treatment of medication-resistant or life-threatening geriatric depression. Neuromodulation therapies (subconvulsive, focal, or subconvulsive and focal) are alternatives for the management of treatment-resistant depression in the elderly. Therapies that combine both strategies could be safer but may not be as effective as ECT. This review covers the evidence on the safety and efficacy of ECT and the neuromodulation therapies in geriatric depression.
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Affiliation(s)
- Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University, 101 Woodruff Cir NE, Suite 4000, Atlanta, GA 30322, USA
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Deng ZD, Lisanby SH, Peterchev AV. Controlling stimulation strength and focality in electroconvulsive therapy via current amplitude and electrode size and spacing: comparison with magnetic seizure therapy. J ECT 2013; 29:325-35. [PMID: 24263276 PMCID: PMC3905244 DOI: 10.1097/yct.10.1097/yct.0b013e3182a4b4a7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Understanding the relationship between the stimulus parameters of electroconvulsive therapy (ECT) and the electric field characteristics could guide studies on improving risk/benefit ratio. We aimed to determine the effect of current amplitude and electrode size and spacing on the ECT electric field characteristics, compare ECT focality with magnetic seizure therapy (MST), and evaluate stimulus individualization by current amplitude adjustment. METHODS Electroconvulsive therapy and double-cone-coil MST electric field was simulated in a 5-shell spherical human head model. A range of ECT electrode diameters (2-5 cm), spacing (1-25 cm), and current amplitudes (0-900 mA) was explored. The head model parameters were varied to examine the stimulus current adjustment required to compensate for interindividual anatomical differences. RESULTS By reducing the electrode size, spacing, and current, the ECT electric field can be more focal and superficial without increasing scalp current density. By appropriately adjusting the electrode configuration and current, the ECT electric field characteristics can be made to approximate those of MST within 15%. Most electric field characteristics in ECT are more sensitive to head anatomy variation than in MST, especially for close electrode spacing. Nevertheless, ECT current amplitude adjustment of less than 70% can compensate for interindividual anatomical variability. CONCLUSIONS The strength and focality of ECT can be varied over a wide range by adjusting the electrode size, spacing, and current. If desirable, ECT can be made as focal as MST while using simpler stimulation equipment. Current amplitude individualization can compensate for interindividual anatomical variability.
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Affiliation(s)
- Zhi-De Deng
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Department of Electrical Engineering, Columbia University, New York, NY, USA
| | - Sarah H. Lisanby
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Department of Psychology and Neuroscience, Duke University, Durham, NC, USA
| | - Angel V. Peterchev
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Department of Biomedical Engineering and Department of Electrical and Computer Engineering, Duke University, Durham, NC, USA
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Russell MJ, Goodman T, Pierson R, Shepherd S, Wang Q, Groshong B, Wiley DF. Individual differences in transcranial electrical stimulation current density. J Biomed Res 2013; 27:495-508. [PMID: 24285948 PMCID: PMC3841475 DOI: 10.7555/jbr.27.20130074] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 07/16/2013] [Accepted: 07/28/2013] [Indexed: 12/23/2022] Open
Abstract
Transcranial electrical stimulation (TCES) is effective in treating many conditions, but it has not been possible to accurately forecast current density within the complex anatomy of a given subject's head. We sought to predict and verify TCES current densities and determine the variability of these current distributions in patient-specific models based on magnetic resonance imaging (MRI) data. Two experiments were performed. The first experiment estimated conductivity from MRIs and compared the current density results against actual measurements from the scalp surface of 3 subjects. In the second experiment, virtual electrodes were placed on the scalps of 18 subjects to model simulated current densities with 2 mA of virtually applied stimulation. This procedure was repeated for 4 electrode locations. Current densities were then calculated for 75 brain regions. Comparison of modeled and measured external current in experiment 1 yielded a correlation of r = .93. In experiment 2, modeled individual differences were greatest near the electrodes (ten-fold differences were common), but simulated current was found in all regions of the brain. Sites that were distant from the electrodes (e.g. hypothalamus) typically showed two-fold individual differences. MRI-based modeling can effectively predict current densities in individual brains. Significant variation occurs between subjects with the same applied electrode configuration. Individualized MRI-based modeling should be considered in place of the 10-20 system when accurate TCES is needed.
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Guleyupoglu B, Schestatsky P, Edwards D, Fregni F, Bikson M. Classification of methods in transcranial electrical stimulation (tES) and evolving strategy from historical approaches to contemporary innovations. J Neurosci Methods 2013; 219:297-311. [PMID: 23954780 DOI: 10.1016/j.jneumeth.2013.07.016] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 07/17/2013] [Accepted: 07/25/2013] [Indexed: 12/28/2022]
Abstract
Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.
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Affiliation(s)
- Berkan Guleyupoglu
- Neural Engineering Laboratory, Department of Biomedical Engineering, The City College of New York of CUNY, New York, NY 10031, USA
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35
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Blumberger DM, Mulsant BH, Daskalakis ZJ. What is the role of brain stimulation therapies in the treatment of depression? Curr Psychiatry Rep 2013; 15:368. [PMID: 23712719 DOI: 10.1007/s11920-013-0368-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Brain stimulation therapies have demonstrated efficacy in the treatment of depression and treatment-resistant depression (TRD). Non-invasive brain stimulation in the treatment of depression has grown substantially due to their favorable adverse effect profiles. The role of transcranial direct current stimulation in TRD is unclear, but emerging data suggests that it may be an effective add-on treatment. Repetitive transcranial magnetic stimulation has demonstrated efficacy in TRD that is supported by several multicenter randomized controlled trials. Though, vagus nerve stimulation has been found to be effective in some studies, sham controlled studies were equivocal. Electroconvulsive therapy (ECT) is a well-established brain stimulation treatment for severe depression and TRD, yet stigma and cognitive adverse effects limit its wider use. Magnetic seizure therapy has a more favorable cognitive adverse effect profile; however, equivalent efficacy to ECT needs to be established. Deep brain stimulation may play a role in severe TRD and controlled trials are now underway.
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Affiliation(s)
- Daniel M Blumberger
- Campbell Family Research Institute, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, 1001 Queen St. W. Unit 4, Room 115, Toronto, ON M6J 1H4, Canada.
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Nahas Z, Short B, Burns C, Archer M, Schmidt M, Prudic J, Nobler MS, Devanand D, Fitzsimons L, Lisanby SH, Payne N, Perera T, George MS, Sackeim HA. A Feasibility Study of a New Method for Electrically Producing Seizures in Man: Focal Electrically Administered Seizure Therapy [FEAST]. Brain Stimul 2013; 6:403-8. [DOI: 10.1016/j.brs.2013.03.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 02/09/2013] [Accepted: 03/07/2013] [Indexed: 10/27/2022] Open
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George MS, Taylor JJ, Short B. Treating the depressions with superficial brain stimulation methods. HANDBOOK OF CLINICAL NEUROLOGY 2013; 116:399-413. [PMID: 24112912 DOI: 10.1016/b978-0-444-53497-2.00033-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Many, if not most, of the different superficial brain stimulation methods are being either used or investigated to treat the depressions. There are likely many reasons why there is this much interest and research involving brain stimulation treatments for depression, including that the depressions are common, there is dissatisfaction with other treatments, and some patients do not respond to medications or talking therapies. This is coupled with the fact that depressive episodes are a periodic or temporary state of the brain, and that when patients are no longer in that state they return to normal functioning. Additionally, the oldest brain stimulation method, electroconvulsive therapy (ECT), is also the most effective antidepressant available for the acute treatment of depression in patients who do not respond to medications. The newer brain stimulation methods have followed in the path blazed by ECT, showing that stimulation of key regions can cause a change in brain state and treat the depression. After almost 20 years of research, repeated daily repetitive transcranial magnetic stimulation (rTMS) of the prefrontal cortex for several weeks is now also an established clinical treatment for acute episodes. The data are less convincing for the other brain stimulation methods, but all are being investigated. Using brain stimulation (as opposed to medications or talking therapy) to treat depression is a rapidly expanding area of research with already established clear indications. Much more work is needed to understand best which methods should be used in any given patient, and in what order.
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Affiliation(s)
- Mark S George
- Brain Stimulation Division, Psychiatry Department, Medical University of South Carolina, and Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
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38
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Holtzheimer PE, Mayberg HS. Neuromodulation for treatment-resistant depression. F1000 MEDICINE REPORTS 2012. [PMID: 23189091 PMCID: PMC3506219 DOI: 10.3410/m4-22] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Treatment-resistant depression affects at least 1-3% of the US population. This article reviews the current state of focal neuromodulation therapies for treatment-resistant depression, focusing on those treatments published clinical data. These include transcranial magnetic stimulation, transcranial direct current stimulation, magnetic seizure therapy, vagus nerve stimulation, direct cortical stimulation, and deep brain stimulation among others. Of these, only two (transcranial magnetic stimulation and vagus nerve stimulation) currently have US Food and Drug Administration approval for the treatment of depression.
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Affiliation(s)
- Paul E Holtzheimer
- Departments of Psychiatry and Surgery, Dartmouth-Hitchcock Medical Center 5D, One Medical Center Drive, Lebanon NH 03756, USA
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Peterchev AV, Wagner TA, Miranda PC, Nitsche MA, Paulus W, Lisanby SH, Pascual-Leone A, Bikson M. Fundamentals of transcranial electric and magnetic stimulation dose: definition, selection, and reporting practices. Brain Stimul 2012; 5:435-53. [PMID: 22305345 PMCID: PMC3346863 DOI: 10.1016/j.brs.2011.10.001] [Citation(s) in RCA: 227] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 10/05/2011] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The growing use of transcranial electric and magnetic (EM) brain stimulation in basic research and in clinical applications necessitates a clear understanding of what constitutes the dose of EM stimulation and how it should be reported. METHODS This paper provides fundamental definitions and principles for reporting of dose that encompass any transcranial EM brain stimulation protocol. RESULTS The biologic effects of EM stimulation are mediated through an electromagnetic field injected (via electric stimulation) or induced (via magnetic stimulation) in the body. Therefore, transcranial EM stimulation dose ought to be defined by all parameters of the stimulation device that affect the electromagnetic field generated in the body, including the stimulation electrode or coil configuration parameters: shape, size, position, and electrical properties, as well as the electrode or coil current (or voltage) waveform parameters: pulse shape, amplitude, width, polarity, and repetition frequency; duration of and interval between bursts or trains of pulses; total number of pulses; and interval between stimulation sessions and total number of sessions. Knowledge of the electromagnetic field generated in the body may not be sufficient but is necessary to understand the biologic effects of EM stimulation. CONCLUSIONS We believe that reporting of EM stimulation dose should be guided by the principle of reproducibility: sufficient information about the stimulation parameters should be provided so that the dose can be replicated.
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Affiliation(s)
- Angel V Peterchev
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina 27710, USA.
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40
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Lee WH, Deng ZD, Laine AF, Lisanby SH, Peterchev AV. Influence of white matter conductivity anisotropy on electric field strength induced by electroconvulsive therapy. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2012; 2011:5473-6. [PMID: 22255576 DOI: 10.1109/iembs.2011.6091396] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The goal of this study is to investigate the influence of white matter conductivity anisotropy on the electric field strength induced by electroconvulsive therapy (ECT). We created an anatomically-realistic finite element human head model incorporating tissue heterogeneity and white matter conductivity anisotropy using structural magnetic resonance imaging (MRI) and diffusion tensor MRI data. The electric field spatial distributions of three conventional ECT electrode placements (bilateral, bifrontal, and right unilateral) and an experimental electrode configuration, focal electrically administered seizure therapy (FEAST), were computed. A quantitative comparison of the electric field strength was subsequently performed in specific brain regions of interest thought to be associated with side effects of ECT (e.g., hippocampus and in-sula). The results show that neglecting white matter conductivity anisotropy yields a difference up to 19%, 25% and 34% in electric field strength in the whole brain, hippocampus, and insula, respectively. This study suggests that white matter conductivity anisotropy should be taken into account in ECT electric field models.
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Affiliation(s)
- Won Hee Lee
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA.
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Lee WH, Deng ZD, Kim TS, Laine AF, Lisanby SH, Peterchev AV. Regional electric field induced by electroconvulsive therapy in a realistic finite element head model: influence of white matter anisotropic conductivity. Neuroimage 2012; 59:2110-23. [PMID: 22032945 PMCID: PMC3495594 DOI: 10.1016/j.neuroimage.2011.10.029] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Revised: 09/14/2011] [Accepted: 10/10/2011] [Indexed: 11/30/2022] Open
Abstract
We present the first computational study investigating the electric field (E-field) strength generated by various electroconvulsive therapy (ECT) electrode configurations in specific brain regions of interest (ROIs) that have putative roles in the therapeutic action and/or adverse side effects of ECT. This study also characterizes the impact of the white matter (WM) conductivity anisotropy on the E-field distribution. A finite element head model incorporating tissue heterogeneity and WM anisotropic conductivity was constructed based on structural magnetic resonance imaging (MRI) and diffusion tensor MRI data. We computed the spatial E-field distributions generated by three standard ECT electrode placements including bilateral (BL), bifrontal (BF), and right unilateral (RUL) and an investigational electrode configuration for focal electrically administered seizure therapy (FEAST). The key results are that (1) the median E-field strength over the whole brain is 3.9, 1.5, 2.3, and 2.6 V/cm for the BL, BF, RUL, and FEAST electrode configurations, respectively, which coupled with the broad spread of the BL E-field suggests a biophysical basis for observations of superior efficacy of BL ECT compared to BF and RUL ECT; (2) in the hippocampi, BL ECT produces a median E-field of 4.8 V/cm that is 1.5-2.8 times stronger than that for the other electrode configurations, consistent with the more pronounced amnestic effects of BL ECT; and (3) neglecting the WM conductivity anisotropy results in E-field strength error up to 18% overall and up to 39% in specific ROIs, motivating the inclusion of the WM conductivity anisotropy in accurate head models. This computational study demonstrates how the realistic finite element head model incorporating tissue conductivity anisotropy provides quantitative insight into the biophysics of ECT, which may shed light on the differential clinical outcomes seen with various forms of ECT, and may guide the development of novel stimulation paradigms with improved risk/benefit ratio.
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Affiliation(s)
- Won Hee Lee
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27710, USA
| | - Zhi-De Deng
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27710, USA
- Department of Electrical Engineering, Columbia University, New York, NY 10027, USA
| | - Tae-Seong Kim
- Department of Biomedical Engineering, Kyung Hee University, Yongin, Gyeonggi, Republic of Korea
| | - Andrew F. Laine
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
| | - Sarah H. Lisanby
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27710, USA
- Department of Psychology & Neuroscience, Duke University, Durham, NC 27710, USA
| | - Angel V. Peterchev
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27710, USA
- Department of Biomedical Engineering and Department of Electrical and Computer Engineering, Duke University, Durham, NC 27710, USA
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Rosa MA, Lisanby SH. Somatic treatments for mood disorders. Neuropsychopharmacology 2012; 37:102-16. [PMID: 21976043 PMCID: PMC3238088 DOI: 10.1038/npp.2011.225] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 08/18/2011] [Accepted: 08/18/2011] [Indexed: 12/22/2022]
Abstract
Somatic treatments for mood disorders represent a class of interventions available either as a stand-alone option, or in combination with psychopharmacology and/or psychotherapy. Here, we review the currently available techniques, including those already in clinical use and those still under research. Techniques are grouped into the following categories: (1) seizure therapies, including electroconvulsive therapy and magnetic seizure therapy, (2) noninvasive techniques, including repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and cranial electric stimulation, (3) surgical approaches, including vagus nerve stimulation, epidural electrical stimulation, and deep brain stimulation, and (4) technologies on the horizon. Additionally, we discuss novel approaches to the optimization of each treatment, and new techniques that are under active investigation.
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Affiliation(s)
- Moacyr A Rosa
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Sarah H Lisanby
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
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Abstract
OBJECTIVE The aim of this study was to review the current state of development and application of a wide range of brain stimulation approaches in the treatment of psychiatric disorders. METHOD The approaches reviewed include forms of minimally invasive magnetic and electrical stimulation, seizure induction, implanted devices and several highly novel approaches in early development. RESULTS An extensive range of brain stimulation approaches are now being widely used in the treatment of patients with psychiatric disorders, or actively investigated for this use. Both vagal nerve stimulation (VNS) and repetitive transcranial magnetic stimulation (rTMS) have been introduced into clinical practice in some countries. A small body of research suggests that VNS has some potentially long-lasting antidepressant effects in a minority of patients treated. rTMS has now been extensively investigated for over 15 years, with a large body of research now supporting its antidepressant effects. Further rTMS research needs to focus on defining the most appropriate stimulation methods and exploring its longer term use in maintenance protocols. Very early data suggest that magnetic seizure therapy (MST) has promise in the treatment of patients referred for electroconvulsive therapy: MST appears to have fewer side effects and may have similar efficacy. A number of other approaches including surgical and alternative forms of electrical stimulation appear to alter brain activity in a promising manner, but are in need of evaluation in more substantive patient samples. CONCLUSIONS It appears likely that the range of psychiatric treatments available for patients will grow over the coming years to progressively include a number of novel brain stimulation techniques.
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Affiliation(s)
- Paul B Fitzgerald
- Monash Alfred Psychiatry Research Centre, The Alfred and Monash University School of Psychology and Psychiatry, Melbourne, Victoria, Australia. paul.fi
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Novakovic V, Sher L, Lapidus KA, Mindes J, A.Golier J, Yehuda R. Brain stimulation in posttraumatic stress disorder. Eur J Psychotraumatol 2011; 2:EJPT-2-5609. [PMID: 22893803 PMCID: PMC3402102 DOI: 10.3402/ejpt.v2i0.5609] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Revised: 07/25/2011] [Accepted: 09/19/2011] [Indexed: 01/21/2023] Open
Abstract
Posttraumatic stress disorder (PTSD) is a complex, heterogeneous disorder that develops following trauma and often includes perceptual, cognitive, affective, physiological, and psychological features. PTSD is characterized by hyperarousal, intrusive thoughts, exaggerated startle response, flashbacks, nightmares, sleep disturbances, emotional numbness, and persistent avoidance of trauma-associated stimuli. The efficacy of available treatments for PTSD may result in part from relief of associated depressive and anxiety-related symptoms in addition to treatment of core symptoms that derive from reexperiencing, numbing, and hyperarousal. Diverse, heterogeneous mechanisms of action and the ability to act broadly or very locally may enable brain stimulation devices to address PTSD core symptoms in more targeted ways. To achieve this goal, specific theoretical bases derived from novel, well-designed research protocols will be necessary. Brain stimulation devices include both long-used and new electrical and magnetic devices. Electroconvulsive therapy (ECT) and Cranial electrotherapy stimulation (CES) have both been in use for decades; transcranial magnetic stimulation (TMS), magnetic seizure therapy (MST), deep brain stimulation (DBS), transcranial Direct Current Stimulation (tDCS), and vagus nerve stimulation (VNS) have been developed recently, over approximately the past twenty years. The efficacy of brain stimulation has been demonstrated as a treatment for psychiatric and neurological disorders such as anxiety (CES), depression (ECT, CES, rTMS, VNS, DBS), obsessive-compulsive disorder (OCD) (DBS), essential tremor, dystonia (DBS), epilepsy (DBS, VNS), Parkinson Disease (DBS), pain (CES), and insomnia (CES). To date, limited data on brain stimulation for PTSD offer only modest guidance. ECT has shown some efficacy in reducing comorbid depression in PTSD patients but has not been demonstrated to improve most core PTSD symptoms. CES and VNS have shown some efficacy in reducing anxiety, findings that may suggest possible utility in relieving PTSD-associated anxiety. Treatment of animal models of PTSD with DBS suggests potential human benefit. Additional research and novel treatment options for PTSD are urgently needed. The potential usefulness of brain stimulation in treating PTSD deserves further exploration.
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Affiliation(s)
- Vladan Novakovic
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA
- Department of Psychiatry, James J. Peters VA Medical Center, New York, NY, USA
| | - Leo Sher
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA
- Department of Psychiatry, James J. Peters VA Medical Center, New York, NY, USA
| | - Kyle A.B. Lapidus
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA
- Department of Psychiatry, James J. Peters VA Medical Center, New York, NY, USA
| | - Janet Mindes
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA
- Department of Psychiatry, James J. Peters VA Medical Center, New York, NY, USA
| | - Julia A.Golier
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA
- Department of Psychiatry, James J. Peters VA Medical Center, New York, NY, USA
| | - Rachel Yehuda
- Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA
- Department of Psychiatry, James J. Peters VA Medical Center, New York, NY, USA
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Abstract
Major depressive disorder (MDD) is a common psychiatric illness affecting nearly 20% of adults in the United States at least once during their lifetime. MDD is frequently diagnosed and treated in the primary care setting. Management of the disease may be complicated by patients and family members feeling stigmatized by the diagnosis and not understanding that depression is a treatable medical illness, which, in turn, fosters low rates of adherence to treatment recommendations. Incomplete or delayed response to treatment, adverse events associated with antidepressants and medical or psychiatric comorbidities also interfere with optimal depression management. This article presents an overview of diagnostic and treatment guidelines for MDD and focuses on challenges encountered by primary care physicians. The role of antidepressant medications, psychotherapy and nonpharmacologic interventions for the treatment of patients with MDD is described, and factors influencing treatment selection, such as adverse event profiles and patient characteristics, are examined.
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Affiliation(s)
- Karen Weihs
- PsychoOncology Services, Arizona Cancer Center, University of Arizona, Tucson, Arizona, USA.
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Lee WH, Deng ZD, Kim TS, Laine AF, Lisanby SH, Peterchev AV. Regional electric field induced by electroconvulsive therapy: a finite element simulation study. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2011; 2010:2045-8. [PMID: 21096148 DOI: 10.1109/iembs.2010.5626553] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The goal of this study is to investigate the regional distribution of the electric field (E-field) strength induced by electroconvulsive therapy (ECT), and to contrast clinically relevant electrode configurations through finite element (FE) analysis. An FE human head model incorporating tissue heterogeneity and white matter anisotropy was generated based on structural magnetic resonance imaging (MRI) and diffusion tensor MRI (DT-MRI) data. We simulated the E-field spatial distributions of three standard ECT electrode placements [bilateral (BL), bifrontal (BF), and right unilateral (RUL)] and an investigational electrode configuration [focal electrically administered seizure therapy (FEAST)]. A quantitative comparison of the E-field strength was subsequently carried out in various brain regions of interests (ROIs) that have putative role in the therapeutic action and/or adverse side effects of ECT. This study illustrates how the realistic FE head model provides quantitative insight in the biophysics of ECT, which may shed light on the differential clinical outcomes seen with various forms of ECT, and may guide the development of novel stimulation paradigms with improved risk/benefit ratio.
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Affiliation(s)
- Won Hee Lee
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA.
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Deng ZD, Lisanby SH, Peterchev AV. Electric field strength and focality in electroconvulsive therapy and magnetic seizure therapy: a finite element simulation study. J Neural Eng 2011; 8:016007. [PMID: 21248385 PMCID: PMC3903509 DOI: 10.1088/1741-2560/8/1/016007] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We present the first computational study comparing the electric field induced by various electroconvulsive therapy (ECT) and magnetic seizure therapy (MST) paradigms. Four ECT electrode configurations (bilateral, bifrontal, right unilateral, and focal electrically administered seizure therapy) and three MST coil configurations (circular, cap, and double cone) were modeled. The model incorporated a modality-specific neural activation threshold. ECT (0.3 ms pulse width) and MST induced the maximum electric field of 2.1-2.5 V cm⁻¹ and 1.1-2.2 V cm⁻¹ in the brain, corresponding to 6.2-7.2 times and 1.2-2.3 times the neural activation threshold, respectively. The MST electric field is more confined to the superficial cortex compared to ECT. The brain volume stimulated was much larger with ECT (up to 100%) than with MST (up to 8.2%). MST with the double-cone coil was the most focal, and bilateral ECT was the least focal. Our results suggest a possible biophysical explanation of the reduced side effects of MST compared to ECT. Our results also indicate that the conventional ECT pulse amplitude (800-900 mA) is much higher than necessary for seizure induction. Reducing the ECT pulse amplitude should be explored as a potential means of diminishing side effects.
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Affiliation(s)
- Zhi-De Deng
- Division of Brain Stimulation and Therapeutic Modulation, Department of Psychiatry, ColumbiaUniversity/New York State Psychiatric Institute, 1051 Riverside Drive, Unit 21, New York, NY 10032, USA
- Department of Electrical Engineering, Columbia University, 1300 S. W. Mudd, 500 West 120th Street, New York, NY 10027, USA
| | - Sarah H. Lisanby
- Division of Brain Stimulation and Therapeutic Modulation, Department of Psychiatry, ColumbiaUniversity/New York State Psychiatric Institute, 1051 Riverside Drive, Unit 21, New York, NY 10032, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Box 3950 DUMC, Durham, NC27710, USA
| | - Angel V. Peterchev
- Division of Brain Stimulation and Therapeutic Modulation, Department of Psychiatry, ColumbiaUniversity/New York State Psychiatric Institute, 1051 Riverside Drive, Unit 21, New York, NY 10032, USA
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48
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Abstract
In this article, we review the parameters that define the electroconvulsive therapy (ECT) electrical stimulus and discuss their biophysical roles. We also present the summary metrics of charge and energy that are conventionally used to describe the dose of ECT and the rules commonly deployed to individualize the dose for each patient. We then highlight the limitations of these summary metrics and dosing rules in that they do not adequately capture the roles of the distinct stimulus parameters. Specifically, there is strong theoretical and empirical evidence that stimulus parameters (pulse amplitude, shape, and width, and train frequency, directionality, polarity, and duration) exert unique neurobiological effects that are important for understanding ECT outcomes. Consideration of the distinct stimulus parameters, in conjunction with electrode placement, is central to further optimization of ECT dosing paradigms to improve the risk-benefit ratio. Indeed, manipulation of specific parameters, such as reduction of pulse width and increase in number of pulses, has already resulted in dramatic reduction of adverse effects, while maintaining efficacy. Furthermore, the manipulation of other parameters, such as current amplitude, which are commonly held at fixed, high values, might be productively examined as additional means of targeting and individualizing the stimulus, potentially reducing adverse effects. We recommend that ECT dose be defined using all stimulus parameters rather than a summary metric. All stimulus parameters should be noted in treatment records and published reports. To enable research on optimization of dosing paradigms, we suggest that ECT devices provide capabilities to adjust and display all stimulus parameters.
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Deng ZD, Lisanby SH, Peterchev AV. Effect of anatomical variability on neural stimulation strength and focality in electroconvulsive therapy (ECT) and magnetic seizure therapy (MST). ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2010; 2009:682-8. [PMID: 19964484 DOI: 10.1109/iembs.2009.5334091] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We present a quantitative comparison of two metrics-neural stimulation strength and focality-in electrocon-vulsive therapy (ECT) and magnetic seizure therapy (MST) using finite-element method (FEM) simulation in a spherical head model. Five stimulation modalities were modeled, including bilateral ECT, unilateral ECT, focal electrically administered seizure therapy (FEAST), and MST with circular and double-cone coils, with stimulation parameters identical to those applied in clinical practice. We further examine the effect on the stimulation metrics of individual-, sex- and age-related variability in tissue layer thickness and conductivity. Neural stimulation by MST is shown to be more focal and superficial than ECT. This result suggests that it may be advantageous to reduce the current used in ECT. The stimulation strength in MST is also less sensitive to variations in head geometry and tissue conductivity than in ECT. Individualization of pulse amplitude in both ECT and MST could compensate for anatomical variability, which could lead to more consistent clinical outcomes.
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Affiliation(s)
- Zhi-De Deng
- Department of Electrical Engineering and with the Division of Brain Stimulation and Therapeutic Modulation, Department of Psychiatry, Columbia University, New York, NY 10032, USA.
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Rowny SB, Benzl K, Lisanby SH. Translational development strategy for magnetic seizure therapy. Exp Neurol 2009; 219:27-35. [PMID: 19348798 DOI: 10.1016/j.expneurol.2009.03.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Revised: 03/18/2009] [Accepted: 03/19/2009] [Indexed: 10/20/2022]
Abstract
Electroconvulsive therapy (ECT) has unparalleled antidepressant efficacy, but its cognitive side effects may be persistent. Research suggests that the side effects may be at least partially dissociable from the therapeutic effects of ECT, suggesting that distinct cortical networks may underlie them and introducing a role for focal seizure induction as a means of minimizing side effects. In magnetic seizure therapy (MST), magnetic fields avoid tissue impedance and induce electrical currents confined to superficial cortex, facilitating focal seizure induction. The translational development strategy for MST has included: (1) device development, (2) feasibility in animals and initial human trials, (3) testing in nonhuman primates on safety and mechanisms of action (with neuroanatomical, neurophysiological and cognitive endpoints), (4) safety testing in patients, (5) initial efficacy testing in patients, (6) dosage optimization, and (7) randomized comparison with ECT. These stages have been iterative, with results of early clinical testing prompting device enhancements that were, in turn, tested in nonhuman primates prior to human trials. Safety testing was aided by development of a nonhuman primate model of human ECT, and the validation of a cognitive battery for the monkey that is sensitive to the range of effects of ECT on human memory. Human testing has been facilitated by the development of an international consortium of centers addressing various aspects of technique and dose/response relationships. Challenges facing MST are common to other device-based therapies: characterizing dose/response relationships, optimizing efficacy, and developing efficient and reliable methods to induce lasting therapeutic change in the circuitry underlying depression.
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Affiliation(s)
- Stefan B Rowny
- Brain Stimulation and Therapeutic Modulation Division, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, 1051 Riverside Drive, Unit 21, New York, NY 10032, USA.
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