ECT in the 21st century: optimizing treatment: state of the art in the 21st century

Electroconvulsive Therapy and Age: Effectiveness, Safety and Tolerability in the Treatment of Major Depression among Patients under and over 65 Years of Age

Electroconvulsive therapy (ECT) remains the most effective therapy in treatment-resistant depression. However, the safety of ECT has been consistently questioned, particularly among elderly patients. We assessed the efficacy and safety of ECT in patients before and after 65 years old. The study was conducted between 2015 and 2018 and included 91 patients (61 under and 29 over 65 years old) with major depression undergoing ECT. The Hamilton Depression Rating Scale was used to evaluate efficacy. Cognitive functions were assessed using: MMSE, RAVLT, Trail Making Test, Stroop Test and Autobiographical Memory Interview-Short Form. ECT was more effective in older patients as compared to younger (p < 0.001). No serious adverse events were observed in either group. Increased blood pressure and arrhythmias were more common in the older compared to the younger group (p = 0.044 and p = 0.047, respectively), while disturbances of consciousness did not differ between groups (p = 0.820). Most of the cognitive functions remained unchanged compared to baseline, whereas the outcomes of MMSE, RAVLT and Stroop tests showed greater improvements in the older compared to the younger group (all p < 0.05). The decline in the retrieval consistency of autobiographical memory was more pronounced in the younger group (p = 0.024). ECT is a highly effective, safe and well-tolerated method of treating depression regardless of age.

Systematic Review of the Neural Effect of Electroconvulsive Therapy in Patients with Schizophrenia: Hippocampus and Insula as the Key Regions of Modulation

OBJECTIVE

Electroconvulsive therapy (ECT) has been the most potent treatment option for treatment-resistant schizophrenia (TRS). However, the underlying neural mechanisms of ECT in schizophrenia remain largely unclear. This paper examines studies that investigated structural and functional changes after ECT in patients with schizophrenia.

METHODS

We carried out a systematic review with following terms: 'ECT', 'schizophrenia', and the terms of various neuroimaging modalities.

RESULTS

Among the 325 records available from the initial search in May 2020, 17 studies were included. Cerebral blood flow in the frontal, temporal, and striatal structures was shown to be modulated (n=3), although the results were divergent. Magnetic resonance spectroscopy (MRS) studies suggested that the ratio of N-acetyl-aspartate/creatinine was increased in the left prefrontal cortex (PFC; n=2) and left thalamus (n=1). The hippocampus and insula (n=6, respectively) were the most common regions of structural/functional modulation, which also showed symptom associations. Functional connectivity of the default mode network (DMN; n=5), PFC (n=4), and thalamostriatal system (n=2) were also commonly modulated.

CONCLUSION

Despite proven effectiveness, there has been a dearth of studies investigating the neurobiological mechanisms underlying ECT. There is preliminary evidence of structural and functional modulation of the hippocampus and insula, functional changes in the DMN, PFC, and thalamostriatal system after ECT in patients with schizophrenia. We discuss the rationale and implications of these findings and the potential mechanism of action of ECT. More studies evaluating the mechanisms of ECT are needed, which could provide a unique window into what leads to treatment response in the otherwise refractory TRS population.

Cognitive side-effects of electroconvulsive therapy: what are they, how to monitor them and what to tell patients

BACKGROUND

Electroconvulsive therapy (ECT) is recommended in treatment guidelines as an efficacious therapy for treatment-resistant depression. However, it has been associated with loss of autobiographical memory and short-term reduction in new learning.

AIMS

To provide clinically useful guidelines to aid clinicians in informing patients regarding the cognitive side-effects of ECT and in monitoring these during a course of ECT, using complex data.

METHOD

A Committee of clinical and academic experts from Australia and New Zealand met to the discuss the key issues pertaining to ECT and cognitive side-effects. Evidence regarding cognitive side-effects was reviewed, as was the limited evidence regarding how to monitor them. Both issues were supplemented by the clinical experience of the authors.

RESULTS

Meta-analyses suggest that new learning is impaired immediately following ECT but that group mean scores return at least to baseline by 14 days after ECT. Other cognitive functions are generally unaffected. However, the finding of a mean score that is not reduced from baseline cannot be taken to indicate that impairment, particularly of new learning, cannot occur in individuals, particularly those who are at greater risk. Therefore, monitoring is still important. Evidence suggests that ECT does cause deficits in autobiographical memory. The evidence for schedules of testing to monitor cognitive side-effects is currently limited. We therefore make practical recommendations based on clinical experience.

CONCLUSIONS

Despite modern ECT techniques, cognitive side-effects remain an important issue, although their nature and degree remains to be clarified fully. In these circumstances it is useful for clinicians to have guidance regarding what to tell patients and how to monitor these side-effects clinically.

Systematic Monitoring of Cognitive Function During Electroconvulsive Therapy: A Retrospective Analysis of Data From a Service Using a Short Cognitive Testing Battery

OBJECTIVE

International guidelines suggest repeating cognitive testing at intervals throughout a course of electroconvulsive therapy (ECT) to monitor its effects on cognitive function. However, it is apparent that few services do this, and an optimal battery of testing has not yet been established. We aimed to evaluate the utility of such routine cognitive testing in a clinic where patients had been routinely tested at intervals throughout a course of ECT.

METHODS

All patients referred for ECT at a public ECT clinic were offered routine cognitive testing to monitor cognitive function during their course of ECT. Testing was conducted at baseline and after 3, 6, and 9 treatments. Analyses examined whether change in individual measures predicted reduction in autobiographical memory at subsequent measures and whether the results that were given to clinicians informed treatment decisions.

RESULTS

Changes in cognitive test results were not associated with clinician decisions to change treatment parameters. Only change in digit span forwards after 3 treatments was associated with later reduction in Colombia University Autobiographical Interview - Short Form (CUAMI-SF) of greater than 25%, with a larger improvement in digit span forwards being associated with greater chance of having a 25% reduction in CUAMI-SF.

CONCLUSIONS

There was no evidence that the screening undertaken in this clinic had been helpful in determining treatment decisions or that changes in cognitive tests predicted in a reliable way who would later experience changes in autobiographical memory. However, follow-up testing was not completed reliably, and longer-term data regarding autobiographical memory were not collected.

Neuroimaging Biomarkers at Baseline Predict Electroconvulsive Therapy Overall Clinical Response in Depression: A Systematic Review

OBJECTIVE

Major depressive disorder is a frequent and disabling disease and can be treated with antidepressant drugs. When faced with severe or resistant major depressive disorder, however, psychiatrists may resort to electroconvulsive therapy (ECT). Although very effective, the response falls short of 100%. A recent meta-analysis established clinical and biological predictive factors of the response to ECT. We decided to explore neuroimaging biomarkers that could be predictors of the ECT response.

METHODS

We performed a systematic literature review up to January 1, 2018, using a Boolean combination of MeSH terms. We included 19 studies matching our inclusion criteria.

RESULTS

Lower hippocampal, increased amygdala, and subgenual cingulate gyrus volumes were predictive for a better ECT response. Functional magnetic resonance imaging also found that the connectivity between the dorsolateral prefrontal cortex and posterior default-mode network is predictive of increased efficacy. Conversely, deep white matter hyperintensities in basal ganglia and Virchow-Robin spaces, medial temporal atrophy, ratio of left superior frontal to left rostral middle frontal cortical thickness, cingulate isthmus thickness asymmetry, and a wide range of gray and white matter anomalies were predictive for a poorer response.

CONCLUSIONS

Our review addresses the positive or negative predictive value of neuroimaging biomarkers for the ECT response, indispensable in a personalized medicine dynamic. These data could reduce the risk of nonresponders or resistance with earlier effective management. It might also help researchers elucidate the complex pathophysiology of depressive disorders and the functioning of ECT.

Structural-functional brain changes in depressed patients during and after electroconvulsive therapy

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.

Trigeminal nerve stimulation in major depressive disorder: first proof of concept in an open pilot trial

Modulation of brain activity via trigeminal nerve stimulation is an emerging therapy in drug-resistant epilepsy. This cranial nerve also projects to structures implicated in depression (such as the nucleus tractus solitarius and locus coeruleus). We examined the effects of external trigeminal nerve stimulation in major depressive disorder as an adjunct to pharmacotherapy. Five adults (mean age 49.6, SD 10.9, three females and two males) participated in an 8-week open-label outpatient trial; all had persistent symptoms despite adequate pharmacotherapy, with a mean score on the 28-item Hamilton Depression Rating Scale of 25.4 (SD=3.9) at entry. Nightly stimulation over the V(1) branch was well tolerated. Both the clinician-rated 28-item Hamilton Depression Rating Scale (P=0.006) and the self-rated Beck Depression Inventory (P=0.0004) detected significant symptomatic improvement. This novel neuromodulation approach may have use as an adjunct to pharmacotherapy in major depressive disorder. Additional larger trials are needed to delineate efficacy and tolerability with greater reliability.