Evidence for less improvement in depression in patients taking benzodiazepines during unilateral ECT

Factors Predicting Ictal Quality in Bilateral Electroconvulsive Therapy Sessions

In electroconvulsive therapy (ECT), ictal characteristics predict treatment response and can be modified by changes in seizure threshold and in the ECT technique. We aimed to study the impact of ECT procedure-related variables that interact during each session and might influence the seizure results. Two hundred and fifty sessions of bilateral ECT in forty-seven subjects were included. Seizure results were evaluated by two different scales of combined ictal EEG parameters (seizure quality index (SQI) and seizure adequacy markers sum (SAMS) scores) and postictal suppression rating. Repeated measurement regression analyses were performed to identify predictors of each session’s three outcome variables. Univariate models identified age, physical status, hyperventilation, basal oxygen saturation, days between sessions, benzodiazepines, lithium, and tricyclic antidepressants as predictors of seizure quality. Days elapsed between sessions, higher oxygen saturation and protocolized hyperventilation application were significant predictors of better seizure quality in both scales used in multivariate models. Additionally, lower ASA classification influenced SQI scores as well as benzodiazepine use and lithium daily doses were predictors of SAMS scores. Higher muscle relaxant doses and lower applied stimulus intensities significantly influenced the postictal suppression rating. The study found several modifiable procedural factors that impacted the obtained seizure characteristics; they could be adjusted to optimize ECT session results.

Successful bilateral electroconvulsive therapy in a patient with a seizure disorder taking levetiracetam, lorazepam, and zonisamide: A case report

Electroconvulsive therapy (ECT) may be considered for treatment of severe, treatment-resistant, and emergent depression associated with MDD or bipolar disorder. Patients with epilepsy usually take medications that raise the seizure threshold, which poses challenges during ECT. We report a 66-year-old male with epilepsy taking levetiracetam extended-release (XR), lorazepam, and zonisamide requiring ECT for severe MDD. After literature review, the XR form of levetiracetam was changed to higher doses of the immediate-release (IR) formulation, and zonisamide was discontinued 2 days prior to ECT in the hospital and was resumed when the patient underwent outpatient continuation ECT. The patient was treated to remission after receiving 8 acute bilateral ECT treatments before being transitioned to continuation ECT. We provide a brief review of medication management of antiepileptic drugs and other medications that increase the seizure threshold during ECT. To our knowledge, this is the first reported case describing the management of levetiracetam, lorazepam, and zonisamide concomitantly during ECT. Our case suggests that utilizing the IR formulation of levetiracetam, administering the evening dose early the day prior to the procedure, and temporarily discontinuing zonisamide prior to bilateral ECT is effective for the treatment of severe MDD while maintaining seizure prophylaxis.

The Efficacy and Safety of Concomitant Psychotropic Medication and Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is an effective treatment for severe psychiatric disorders. Patients referred to ECT are often taking multiple medications, many of which can potentially affect the safety and efficacy of their course of ECT. This review evaluates the impact of a variety of psychotropic medications often used in conjunction with ECT and examines strategies to optimize their management. The review encompasses mood stabilizers, antidepressants, benzodiazepines, antiepileptics, antipsychotics, and other commonly used psychotropics.

Use of midazolam for ECT anesthesia: effects on antidepressive efficacy and seizure duration. Preliminary findings

Midazolam is a short acting benzodiazepine that has been used for electroconvulsive therapy (ECT) anesthesia. The purpose of this study was to determine whether midazolam used for this purpose would impair the antidepressive efficacy of ECT. In a double-blind random-assignment study midazolam was compared to methohexital on the antidepressive efficacy of bilateral ECT as measured by the reduction in the Montgomery Asberg Depression Rating Scale (MADRS) scores and seizure duration. Sixteen DSM-III-R major depressive disorder patients with melancholia were included. Midazolam and methohexital did not differ in their effects on the MADRS score or seizure duration; no correlation was found between seizure duration and outcome of depression for either group. Our preliminary findings do not support the claim that benzodiazepines should not be used during bilateral ECT.

Clinical Effectiveness of Maintenance Electroconvulsive Therapy in Patients with Schizophrenia: A Retrospective Cohort Study

OBJECTIVE

This study aimed to assess the clinical effectiveness and cognitive effects of maintenance electroconvulsive therapy (mECT) in patients with schizophrenia or schizoaffective disorder and explore factors associated with both outcomes.

METHODS

In this retrospective cohort study, we examined clinical records of 47 patients with a Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnosis of schizophrenia or schizoaffective disorder treated with mECT at an academic mental health hospital between April 2010 and July 2016. Sixty-two mECT courses were reviewed. We assessed clinical effectiveness and cognitive effects as well as factors associated with response to treatment, including psychiatric diagnosis, concomitant pharmacological treatment, and previous treatment response.

RESULTS

Maintenance electroconvulsive therapy was able to maintain clinical response in 48 (77%) treatment courses. Significant cognitive adverse effects were reported in 7 (11%) of the courses. Use of antipsychotic, antidepressant or benzodiazepine medications, psychiatric disorder, and sex were not associated with response.

CONCLUSION

This study shows meaningful clinical effectiveness and good tolerability of mECT in patients with resistant schizophrenia over extended periods.

Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives

Catatonia is a serious, common syndrome of motoric and behavioral dysfunction, which carries high morbidity and mortality. Electroconvulsive therapy (ECT) is the definitive treatment for catatonia, but access to ECT for the treatment of catatonia remains inappropriately limited. Catatonia is observable, detectable, and relevant to various medical specialties, but underdiagnosis impedes the delivery of appropriate treatment and heightens risk of serious complications including iatrogenesis. Current understanding of catatonia's pathophysiology links it to the current understanding of ECT's mechanism of action. Definitive catatonia care requires recognition of the syndrome, workup to identify and treat the underlying cause, and effective management including appropriate referral for ECT. Even when all of these conditions are met, and despite well-established data on the safety and efficacy of ECT, stigma surrounding ECT and legal restrictions for its use in catatonia are additional critical barriers. Addressing the underdiagnosis of catatonia and barriers to its treatment with ECT is vital to improving outcomes for patients. While no standardized protocols for treatment of catatonia with ECT exist, a large body of research guides evidence-based care and reveals where additional research is warranted. The authors conducted a review of the literature on ECT as a treatment for catatonia. Based on the review, the authors offer strategies and future directions for improving access to ECT for patients with catatonia, and propose an algorithm for the treatment of catatonia with ECT.

How Much Do Benzodiazepines Matter for Electroconvulsive Therapy in Patients With Major Depression?

BACKGROUND

Electroconvulsive therapy (ECT) is one of the most effective treatments for major depressive disorder (MDD), especially in cases of treatment-resistant MDD. Because of their pharmacological profiles, benzodiazepines (BZDs) are suspected to decrease the efficacy of ECT. This study investigated the effect of BZDs on ECT-induced clinical outcomes and ECT course parameters in patients with MDD.

METHOD

The impact of BZDs on severity of depression (Montgomery-Asberg Depression Rating Scale scores) and on ECT course parameters (seizure threshold, clinical and electroencephalographic seizure duration) was investigated in 70 patients with MDD who received an ECT course using dose-titration method (22 received concomitant BZDs).

RESULTS

Lower remission rates (52.0%) and smaller decreases in Montgomery-Asberg Depression Rating Scale scores were observed in the non-BZD group than in the BZD group (81.2%, P = 0.02). There were no significant differences between the 2 groups regarding seizure duration and seizure threshold.

LIMITATIONS

This was a retrospective study. Impact of BZDs on anxiety and cognition was not assessed.

CONCLUSIONS

Benzodiazepines increased the clinical efficacy of ECT when delivered using dose-titration method and bitemporal stimulation. Further studied are needed to understand the interaction between BZDs and ECT on clinical outcomes.

Improvement after two sessions of electroconvulsive therapy predicts final remission in in-patients with major depression

OBJECTIVE

To investigate whether early improvement, measured after two electroconvulsive therapy (ECT) sessions, is a good predictor of eventual remission in severely depressed in-patients receiving ECT.

METHOD

A prospective cohort study was performed that included 89 major depressive disorder in-patients treated with bilateral ECT. Sensitivity, specificity, and predictive values were computed for various definitions of early improvement (15%, 20%, 25%, and 30% reduction on the Montgomery Asberg depression rating scale (MADRS) score) after 1 week (i.e. two sessions) of ECT regarding prediction of remission (final MADRS score ≤ 9).

RESULTS

A 15% reduction in MADRS score appeared to be the best definition of early improvement, with modest sensitivity (51%) and relatively good specificity (79%). Kaplan-Meier analysis showed a more than 2-week shorter time to remission in patients with early improvement compared with patients lacking early improvement.

CONCLUSION

Early improvement during an ECT course may be assessed after two ECT sessions. Such improvement, defined as a 15% reduction in the MADRS score, is a moderately sensitive predictor for eventual remission in an in-patient population with severe major depression.

Should Benzodiazepines and Anticonvulsants Be Used During Electroconvulsive Therapy?: A Case Study and Literature Review

OBJECTIVE

This study aims to investigate the clinical effects of benzodiazepines or anticonvulsant use during a course of electroconvulsive therapy (ECT).

METHOD

A case report study of a patient who received ECT with and without concomitant flurazepam and pregabalin is presented. The literature on the use of benzodiazepines and anticonvulsants during ECT is reviewed.

RESULTS

A woman with treatment resistant depression received a course of ECT while taking flurazepam and pregabalin, but seizures were of short duration and symptomatic improvement was minimal. After discontinuation of flurazepam and pregabalin, a course of right unilateral ultrabrief ECT was associated with adequate seizures and remission of depression and suicidal ideation. Our literature review suggests that benzodiazepines decrease seizure duration, but most evidence shows no association with increased seizure threshold. One prospective RCT and 3 large retrospective studies found that benzodiazepines compromise the efficacy of unilateral but not bilateral ECT. Regarding anticonvulsants, several studies had varied and contradictory results on their effect on seizure duration and seizure threshold. Of the 2 large retrospective studies and 3 RCTs, only 1 retrospective study showed that anticonvulsants decrease the efficacy of ECT.

CONCLUSIONS

Judicious assessment of all medications used in combination with ECT is recommended. Overall, published studies suggest that benzodiazepines and anticonvulsants impact the clinical outcomes of ECT less than what would be expected given their pharmacologic effects. However, there are significant gaps in the literature, including a lack of study on suprathreshold stimulation of right unilateral ECT and the possibility of a greater effect with higher medication doses.

Electroconvulsive therapy for depression with comorbid borderline personality disorder or post-traumatic stress disorder: A matched retrospective cohort study

BACKGROUND

The impact of comorbid borderline personality disorder (BPD) or post-traumatic stress disorder (PTSD) on clinical and cognitive outcomes of electroconvulsive therapy (ECT) in patients with major depressive episodes (MDE) is unknown.

OBJECTIVE

Compare clinical response and adverse cognitive effects for MDE patients with comorbid BPD or PTSD to MDE only.

METHODS

In a matched retrospective cohort study of 75 patients treated with ECT at an academic psychiatric hospital with DSM-IV MDE and either comorbid BPD, PTSD or both (MDE + BPD/PTSD), 75 MDE patients without BPD or PTSD (MDE-only) were matched. We reviewed clinical records to determine treatment response by estimating clinical global impression of improvement (c-CGI) and presence of adverse cognitive effects based on subjective distress or objective impairment. We explored factors associated with response and cognitive effects in the MDE + BPD/PTSD group.

RESULTS

There was no difference in c-CGI response rates between groups (p > 0.017). Secondary analysis of inpatients found lower response rates for MDE + BPD (55.4%) and MDE + BPD + PTSD (55.8%) than MDE-only (82.5%), but not MDE + PTSD (65.0%). There was no difference in adverse cognitive effects in the MDE + BPD/PTSD (23.3%-26.8%) group compared to MDE-only (25.0%). In the MDE + BPD/PTSD group, factors associated with higher response rate were: referral indications other than failed pharmacotherapy, greater number of ECT treatments, presence of adverse cognitive effects, and seizure duration >30 s.

CONCLUSIONS

Despite a lower c-CGI response for inpatients with MDE + BPD, ECT is a viable treatment option for patients in the MDE + BPD/PTSD group with similar adverse cognitive effect profiles to MDE-only.

Seizure Adequacy Markers and the Prediction of Electroconvulsive Therapy Response

OBJECTIVES

Electroconvulsive therapy (ECT) is the most effective therapy for patients with treatment-resistant depression; however, some patients do not respond or relapse in a short time. Electroconvulsive therapy stimulus parameters may be related to the outcome. We carried out a retrospective study review to investigate various ECT parameters in relation to the outcome, clinical variables, and pharmacological treatments. Our aim was to understand which factors could be considered putative seizure quality markers and which are relevant to clinical practice.

METHODS

Two physicians evaluated the seizure length, the postictal suppression index, the wave amplitude, tachycardia, and hemispheric brain wave synchronicity in a double-blind manner for 45 treatment-resistant depression patients receiving ECT.

RESULTS

The analysis showed a significant association between the outcome and the ECT seizure quality measured by the parameters (P = 9.9 × 10). Among patients with poor-quality seizures, 61.5% relapsed after approximately 1 month from the last ECT session. Particularly, there was an association between higher symptomatology decrease and higher quality of hemispheric brain wave synchronicity (P = 5.0 × 10), as well as a higher wave amplitude (P = 0.01).

CONCLUSIONS

Our results confirm that ECT seizure quality was strongly correlated with the decrease of depressive symptomatology.

Structural Plasticity of the Hippocampus and Amygdala Induced by Electroconvulsive Therapy in Major Depression

BACKGROUND

Electroconvulsive therapy (ECT) elicits a rapid and robust clinical response in patients with refractory depression. Neuroimaging measurements of structural plasticity relating to and predictive of ECT response may point to the mechanisms underlying rapid antidepressant effects and establish biomarkers to inform other treatments. Here, we determine the effects of diagnosis and of ECT on global and local variations of hippocampal and amygdala structures in major depression and predictors of ECT-related clinical response.

METHODS

Longitudinal changes in hippocampal and amygdala structures were examined in patients with major depression (N = 43, scanned three times: prior to ECT, after the second ECT session, and within 1 week of completing the ECT treatment series), referred for ECT as part of their standard clinical care. Cross-sectional comparisons with demographically similar controls (N = 32, scanned twice) established effects of diagnosis.

RESULTS

Patients showed smaller hippocampal volumes than controls at baseline (p < .04). Both the hippocampal and the amygdala volumes increased with ECT (p < .001) and in relation to symptom improvement (p < .01). Hippocampal volume at baseline predicted subsequent clinical response (p < .05). Shape analysis revealed pronounced morphometric changes in the anterior hippocampus and basolateral and centromedial amygdala. All structural measurements remained stable across time in controls.

CONCLUSIONS

ECT-induced neuroplasticity in the hippocampus and amygdala relates to improved clinical response and is pronounced in regions with prominent connections to ventromedial prefrontal cortex and other limbic structures. Smaller hippocampal volumes at baseline predict a more robust clinical response. Neurotrophic processes including neurogenesis shown in preclinical studies may underlie these structural changes.

Seizure threshold and the half-age method in bilateral electroconvulsive therapy in Japanese patients

AIM

Seizure threshold (ST) in electroconvulsive therapy (ECT) has not been reported previously in Japanese patients. We investigated ST in bilateral ECT in Japanese patients using the dose-titration method. The associations between demographic and clinical characteristics and ST were analyzed to identify the predictors of ST. Finally, the validity of the half-age method for the stimulus dose was evaluated.

METHODS

Fifty-four Japanese patients with mood disorder, schizophrenia, and other psychotic disorders received an acute course of bilateral ECT using a brief-pulse device. ST was determined at the first session using a fixed titration schedule. ST was correlated with age, sex, body mass index, history of previous ECT, and psychotropic drugs on multiple regression analysis. Furthermore, the rate of accomplished seizures was calculated using the half-age method.

RESULTS

Mean ST was 136 mC. ST was influenced by age, sex, history of previous ECT, and medication with benzodiazepines. The accomplished seizure rate using the half-age method was 72%, which was significantly lower in men and subjects on benzodiazepines.

CONCLUSION

ST in Japanese patients was equal to or slightly higher than that previously reported in other ethnic groups, which might be attributable, at least in part, to high prevalence of and large-dose benzodiazepine prescription. Higher age, male gender, no history of ECT, and benzodiazepines were related to higher ST. The half-age method was especially useful in female patients and subjects without benzodiazepine medication.

Predictors of regained occupational functioning after electroconvulsive therapy (ECT) in patients with major depressive disorder--a population based cohort study

AIMS

The aim of the present study is to investigate the rate of regained occupational functioning among patients treated with electroconvulsive therapy (ECT) for major depression and to define predictors of time to regained occupational functioning.

METHODS

A nested cohort study was performed of patients treated by ECT for unipolar major depressive disorder registered in the Quality register for ECT and in the Swedish Social Insurance Agency registry. Predictive values of single clinical variables and their relative importance were tested with Cox regression analysis.

RESULTS

394 patients were identified. Of those, 266 were on non-permanent sick leave and 128 on disability pension during ECT. Within 1 year post-ECT, 71% of the patients with non-permanent sick leave regained occupational functioning. Factors independently associated with a statistically significant increased time to regained occupational functioning were longer duration of sick leave pre-ECT, milder depression pre-ECT, less complete improvement with ECT, benzodiazepine treatment after ECT and co-morbid substance dependence.

CONCLUSIONS

A large proportion of the patients do not return to work within several months post-ECT. Paradoxically, patients with more severe depression pre-ECT had a reduced time to regained occupational functioning, indicating a larger effect in this patients group of the treatment. Moreover, the period with sick leave compensation might be reduced if ECT is initiated within the first 3 months of sick leave.

CLINICAL IMPLICATIONS

Most patients on non-permanent sick leave regain occupational functioning after ECT. However, it usually takes a few months even in symptomatically improved patients.

Do benzodiazepines moderate the effectiveness of bitemporal electroconvulsive therapy in major depression?

BACKGROUND

Electroconvulsive therapy (ECT) is the most effective treatment for depression. However, the use of concomitant medications during ECT is controversial, especially benzodiazepines, as some past evidence suggests these may reduce the efficacy of ECT. This study analysed the effect of benzodiazepines on treatment outcomes in a group of depressed patients treated with bitemporal (BT) ECT.

METHODS

90 patients with major depression who received BT ECT were analysed. Clinical, demographic and ECT data were extracted from clinical records. Mood improvement was rated by trained psychiatrists using the Hamilton Depression Rating Scale (HDRS-21) at baseline and after the final ECT treatment. The association between benzodiazepine dose and mood outcomes over the ECT course was examined with regression analyses, controlling for variables that may affect ECT efficacy.

RESULTS

Hierarchical multiple regression analysis found only current episode duration (t=-4.77, p<0.001) was a significant predictor of change in HDRS. Benzodiazepine dose was not associated with a change in HDRS (p>0.05, R(2)=0.39).

LIMITATIONS

This was a retrospective study. The use of the half-age dosing method for ECT did not permit examination of the effects of benzodiazepines on seizure threshold.

CONCLUSIONS

Benzodiazepines did not affect the efficacy of BT ECT with the dosing method used. However, these results may not generalise to other forms of ECT, ECT given with other methods of dose determination or to other populations less responsive to ECT.

Position statement and guidelines on unmodified electroconvulsive therapy

BACKGROUND

In modern day psychiatric practice, it is assumed as a matter of fact that when electroconvulsive therapy (ECT) is administered, it will be administered under anesthesia and with succinylcholine (or its equivalent) modification. Yet, as surveys indicate, there is considerable practice of unmodified ECT in developing countries and, to a small extent, in the developed world, as well.

MATERIALS AND METHODS

This document examines historical and recent literature on the geographical practice, physiology, efficacy, and adverse effects of unmodified ECT. Particular attention is paid to musculoskeletal risks.

RESULTS

Although almost all the research is of poor methodological quality, there is a good reason to accept that unmodified ECT is associated with a wide range of adverse consequences, important among which are musculoskeletal complications, pre-ECT anxiety, and post-ECT confusion. However, it appears from recent data that these risks are not as large as historically portrayed. Possibly explanations are suggested, with seizure modification using parenteral benzodiazepines as a special possibility.

CONCLUSIONS

Under exceptional circumstances, if ECT is strongly indicated and seizure modification with succinylcholine is not feasible, unmodified ECT, especially benzodiazepine-modified ECT, may be a viable option. A detailed set of recommendations for such use of unmodified ECT is proposed along with necessary checks and balances. This document has been approved by the Indian Psychatric Society, the Indian Association of Biological Psychiatry, and the Indian Association of Private Psychiatry (which commissioned the preparation of the document).

Electroconvulsive therapy (ECT) in bipolar disorder: A narrative review of literature

In many countries including India electroconvulsive therapy (ECT) is frequently used to treat different phases of bipolar disorder. The response to ECT is impressive in mania, depression and in mixed affective states. Preliminary evidence also suggests benefit from maintenance ECT in bipolar disorder. However, most of the literature on efficacy and adverse effects comes from case series, retrospective reports and open trials - controlled trials have been few and far between. Official guidelines recommend the use of ECT only when there is a dire emergency or when all other options have been exhausted. Concurrent use of lithium and antiepileptic drugs along with ECT is common in clinical practice. While such practice appears to be largely safe, one should be mindful about dose of lithium and possible interference of antiepileptic drugs with efficacy of ECT. The use of suprathreshold bilateral ECT and bifrontal placement of electrodes may confer some advantage over other methods.

Continuation and maintenance electroconvulsive therapy for mood disorders: review of the literature

BACKGROUND

Electroconvulsive therapy (ECT) is a highly effective treatment for mood disorders. Continuation ECT (C-ECT) and maintenance ECT (M-ECT) are required for many patients suffering from severe and recurrent forms of mood disorders. This is a review of the literature regarding C- and M-ECT.

METHODS

We conducted a computerized search using the words continuation ECT, maintenance ECT, depression, mania, bipolar disorder and mood disorders. We report on all articles published in the English language from 1998 to 2009.

RESULTS

We identified 32 reports. There were 24 case reports and retrospective reviews on 284 patients. Two of these reports included comparison groups, and 1 had a prospective follow-up in a subset of subjects. There were 6 prospective naturalistic studies and 2 randomized controlled trials.

CONCLUSIONS

C-ECT and M-ECT are valuable treatment modalities to prevent relapse and recurrence of mood disorders in patients who have responded to an index course of ECT. C-ECT and M-ECT are underused and insufficiently studied despite positive clinical experience of more than 70 years. Studies which are currently under way should allow more definitive recommendations regarding the choice, frequency and duration of C-ECT and M-ECT following acute ECT.

The safety and efficacy of benzodiazepine-modified treatments as a special form of unmodified ECT

BACKGROUND

Muscle relaxants reduce musculoskeletal morbidity with electroconvulsive therapy (ECT) but need to be administered under general anesthesia. The administration of anesthesia is not always possible for patients prescribed ECT. Consequently, unmodified ECT is still widely practiced, especially in developing countries.

METHODS

We prospectively assessed musculoskeletal morbidity in consecutive patients who received unmodified bitemporal ECT during a part or the whole of their ECT course. All patients were pretreated with an intravenous benzodiazepine (usually diazepam, 10 mg) to effect sedation, anxiolysis, and limited skeletal muscle relaxation. Anteroposterior and lateral digital x-rays of the thoracolumbar spine were obtained after the last unmodified treatment.

RESULTS

Fifty-six patients aged 11 to 49 years and with a mean body mass index of 23.0 received a total of 162 (mean, 2.9) unmodified ECTs. There was significant attenuation of psychopathology ratings. Against our expectations, no patient developed clinical or radiological evidence of orthopedic morbidity; however, in 2 patients, the x-rays revealed old spinal fractures. Twelve patients had spots of oral bleeding after ECT. Whereas 5 patients experienced mild, transient, self-limiting postictal confusion, only one had confusion which required medical termination. Five patients complained of body ache and one of memory impairment. There were no other adverse events.

CONCLUSIONS

The complete absence of orthopedic morbidity with benzodiazepine-modified ECT contrasts with historical descriptions of a 20% to 40% risk with unmodified ECT. We speculate that the limited muscle relaxant action of the pre-ECT parenteral benzodiazepine may have had protective effects. If so, if ECT is urgently indicated but anesthesia and hence conventional muscle relaxants cannot be administered, benzodiazepine-modified ECT may be a safer alternative to unmodified ECT. This suggestion merits wide attention because of its public health importance in countries with poor medical infrastructure, where unmodified ECT is still widely practiced.

Seizure threshold determination for electroconvulsive therapy: stimulus dose titration versus age-based estimations

OBJECTIVE

This study compared electroconvulsive therapy (ECT) seizure threshold determined by stimulus dose titration with age-based estimations.

METHOD

Patients with major depressive disorder had their initial seizure thresholds determined by stimulus dose titration and the results compared with age-based estimations. There are no significant differences in thresholds determined by these methods.

RESULTS

Two hundred and three psychiatric patients (149 females, 54 males) had their seizure thresholds determined by stimulus dose titration. There was a significant positive correlation between seizure thresholds and age for males and females with male thresholds greater than female thresholds. Age determinations of seizure threshold would have resulted in excessive initial treatment stimuli for 30% of females and 8% of males. Ineffective stimulus doses would have been given to 2% of females and 7% of males on a full age basis and 64% using a half age strategy.

CONCLUSIONS

For effective high-dose right unilateral ECT, initial seizure threshold should be determined by stimulus dose titration.

Interactions between psychotropics, anaesthetics and electroconvulsive therapy: implications for drug choice and patient management

Despite many predictions that electroconvulsive therapy (ECT) would be replaced by pharmacotherapy, ECT has remained an invaluable adjunct in the management of severe psychiatric disease. Both pharmacotherapy and ECT continue to be used extensively, and will frequently be administered concurrently. The majority of patients requiring ECT will need anaesthesia; therefore, interactions could conceivably occur between the psychotropic drugs, ECT and the anaesthetic agents utilised. In managing an anaesthetic for ECT the effects of the anaesthetic agents and other medications on seizure intensity are important determinants influencing outcome. With regard to the antidepressants, tricyclic antidepressants (TCAs) and ECT can be combined safely and beneficially. More care is required when ECT is administered in the setting of a monoamine oxidase inhibitor (MAOI), especially the older irreversible varieties and in patients recently placed on MAOI therapy. Of the anticonvulsants and mood stabilisers, lithium and ECT given concurrently add significant risk of delirium and/or organic syndromes developing. Possible concerns with valproate, carbamazepine, lamotrigine, gabapentin and topiramate are that they may inhibit seizure activity. Additionally, carbamazepine may prolong the action of suxamethonium (succinylcholine). The combination of antipsychotics and ECT is well tolerated, and may in fact be beneficial. As regards the anxiolytics, benzodiazepines have anticonvulsant properties that might interfere with the therapeutic efficacy of ECT. CNS stimulants on the other hand may prolong seizures as well as produce dysrhythmias and elevate blood pressure. Calcium channel antagonists should be used with great care to avoid significant cardiovascular depression. The anaesthesiologist should therefore remain vigilant at all times, as untoward responses during ECT might occur suddenly due to interactions between psychotropics, anaesthetic agents and/or ECT.

Stimulus titration and ECT dosing

The seizure threshold to electroconvulsive therapy (ECT) is defined entirely by the duration of the induced seizure, is multidetermined, and varies enormously with a wide variety of patient and treatment factors, including especially the parameters of the ECT stimulus. No consistent relationship has ever been detected between the clinical antidepressant response to ECT and either the threshold or the duration of the induced seizure. The stimulus titration method for determining the seizure threshold (titration-threshold dosing) was the central research tool used to reverse years of dogma by proving that the induced seizure of ECT is not alone sufficient to explain the therapeutic properties of ECT, and that the interaction between dosage and treatment electrode placement is critical in this regard. In clinical use, however, titration-threshold dosing has proven less than fully effective in optimizing the stimulus dose for ECT-better results are consistently obtained with age-based or fixed high-dose methods. The lack of a direct correlation between either seizure threshold or duration and clinical ECT response is an irremediable flaw of the titration-threshold method as clinically applied. New approaches are now called for in which ECT stimulus dosage is set and adjusted ("titrated") according to the clinical antidepressant response of the patient or to measurable correlates thereof: maximum sustained electroencephalogram (EEG) ictal power, EEG postictal suppression, induced interictal EEG delta activity, peak heart rate, maximum sustained EEG coherence, and postictal EEG coherence reduction, all of which have been found by various investigators to be related to the clinical antidepressant response to ECT.

Differential response to right unilateral ECT in depressed patients: impact of comorbidity and severity of illness [ISRCTN39974945]

BACKGROUND

Recent electroconvulsive therapy (ECT) efficacy studies of right unilateral (RUL) ECT may not apply to real life clinics with a wide range of patients with major depressive episodes.

METHODS

The study included two groups of patients. In addition to a homogeneous group of patients with major depression according to DSM-IV criteria with severity of the major depressive episode > 16 scores on 17-item Hamilton Rating Scale for Depression (HDRS) (Group 1, n = 16), we included a heterogeneous group of patients with less severe major depressive episodes or with a variety of comorbid conditions (Group 2, n = 24). We randomly assigned the patients to an RUL ECT treatment dosed at 5 or 2.5 times seizure threshold with an intent-to-treat design. The outcomes measured blindly were HDRS, number of treatments, and Mini-Mental State Examination (MMSE). The patients were considered to have responded to treatment if the improvement in HDRS score was at least 60% and they had a total score of less than ten.

RESULTS

The Group 2 patients responded poorer (8% vs. 63%), and had more often simultaneous worsening in their MMSE scores than Group 1 patients. The differences in the outcomes between the two different doses of RUL ECT treatment were not statistically significant.

CONCLUSIONS

ECT effectiveness seems to be lower in real-life heterogeneous patient groups than in homogeneous patient samples used in experimental efficacy trials.

Characteristics of responders and nonresponders to brief-pulse right unilateral ECT in a controlled clinical trial

In a double-blind, randomized controlled study of electroconvulsive therapy (ECT) in patients with major depression, 7 of the 17 patients allocated to the right unilateral group failed to respond to treatment. The nonresponders were subsequently openly treated with bitemporal treatment, which produced an acceptable outcome in these cases of right unilateral treatment failure. This paper describes the clinical outcome, electrophysiological characteristics (impedence, estimated seizure threshold, and change in threshold), and the degree to which stimuli exceeded threshold in the responder and nonresponder groups. Responders had lower seizure thresholds and longer seizures than nonresponders. In comparison with nonresponders, responders showed trends toward greater impedance and treatment at a somewhat greater degree above threshold during the first few treatments. Threshold change with treatment was found not to be related to clinical outcome. Early identification of patients likely to respond to low-dose right unilateral ECT, together with the avoidance of benzodiazepine prescription during ECT, may permit many patients to receive low-dose right unilateral ECT successfully and with a minimum of cognitive impairment.

Synergism of lorazepam and electroconvulsive therapy in the treatment of catatonia

Electroconvulsive therapy (ECT) and lorazepam are effective treatments for catatonia. ECT combined with benzodiazepines has been associated with reduced efficacy and efficiency and therefore is not recommended in the routine practice of ECT. We report 5 prospectively identified cases of catatonia treated either sequentially or concurrently with lorazepam and ECT. In each case, the combination of lorazepam with ECT was superior to monotherapy. This apparent synergism, its possible mechanisms, and its implications for treating catatonia are discussed.

Addressing issues of face validity in the application of a clinical guideline

In 1995, a statewide project to improve the practice of electroconvulsive therapy (ECT) in the Medicare population was started in Louisiana. A retrospective baseline study found high concurrent utilization of lithium and benzodiazepines, medications considered detrimental to ECT by the second American Psychiatric Association Task Force on ECT. Resistance to a clinical guideline because of lack of face validity by clinicians was used as an opportunity to involve clinicians in using data to evaluate their clinical practices. Results of the first two quarters of the project demonstrated that the strategy was successful.

Do SSRIs prolong seizure duration during ECT?

The effect of selective serotonin re-uptake inhibitors (SSRIs) on seizure duration during a course of electroconvulsive therapy (ECT) was evaluated in a retrospective study. Although numbers in the SSRI group were small (n=13), there was a significantly longer seizure duration with SSRIs, compared with tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). More studies are needed to see whether this is a general finding or whether it reflects individual variation, and most importantly, what effects, if any, this has on clinical outcome.

Decreased efficacy of combined benzodiazepines and unilateral ECT in treatment of depression

In a retrospective study, 124 patients with depression who were concomitantly receiving ECT and benzodiazepines were compared with patients (matched for age, sex, diagnosis, and laterality of ECT) receiving ECT without benzodiazepines in order to investigate the efficacy of ECT in terms of therapeutic response and length of stay in hospital. Most of the subjects (84% of cases and 89% of controls) improved on ECT, but the benzodiazepine group of patients receiving unilateral ECT showed a significantly poorer response and a longer stay in hospital. No such difference was detected with the bilateral ECT. It is therefore concluded that prescription of benzodiazepines with ECT does compromise the therapeutic effect of unilateral ECT for depression.

The current status of seizure duration in the practice of electroconvulsive therapy

OBJECTIVE

To critically review data relating the seizure duration in electroconvulsive therapy (ECT) to its therapeutic effect in the treatment of depressive illness.

METHOD

The authors used MEDLINE, PSYCHINFO on CDROM, and their own knowledge of the literature to find studies or reviews concerning the role of seizure duration in ECT efficacy.

RESULTS

Rigorous studies cast doubt on the usefulness of seizure duration as a clinical marker. Some medications that decrease seizure time have deleterious treatment effects but also affect other seizure dynamics. Several medications dramatically shorten seizures but have no influence on treatment efficacy.

CONCLUSION

The guidelines of ECT seizure length are arbitrary, suggesting exaggerated durations for ECT treatment.

The effect of psychotropic medication on seizure duration during bilateral electroconvulsive therapy: a retrospective study

A five-year retrospective study investigating the effects of psychotropic medication on first seizure length was undertaken on 109 patients who received 131 courses of electroconvulsive therapy (ECT). Bilateral ECT was administered under methohexitone anaesthesia. Induction of a seizure was successful in 105 patients. Stepwise linear regression analysis showed that except for selective serotonin reuptake inhibitors (SSRIs) seizure length was not affected by psychotropic medication, SSRIs were associated with prolonged seizure length (p=0.0012). Less than one-third of the subjects had drugs with anticonvulsant properties omitted before treatment. Drugs with anticonvulsant properties did not shorten seizure length. Though this study suggests that SSRIs may prolong fit length, further clarification of the predictors for seizure duration is required.

Seizure threshold in electroconvulsive therapy: I. Initial seizure threshold

We measured initial seizure threshold by means of a structured stimulus dosage titration procedure in a clinical sample of 111 depressed patients undergoing brief-pulse, constant-current electroconvulsive therapy (ECT). Initial seizure threshold was approximately 60 millicoumbs (mc) (10 Joules) on average, but varied widely (6-fold) across patients. Initial seizure threshold was predicted by four variables: electrode placement (higher with bilateral), gender (higher in men), age (higher with increasing age), and dynamic impedance (inverse relationship). Use of neuroleptic medication was associated with a lower seizure threshold. EEG seizure duration was inversely related to initial seizure threshold, but no other relations with seizure duration were found. These findings may have important clinical implications for stimulus dosing strategies in ECT.

Electrode placement, stimulus dosing and seizure monitoring during ECT

Electroconvulsive therapy is one of the most useful, safe and predictable treatment modalities in psychiatry. For optimal results proper application of the procedure is essential. Over the years the procedure has undergone considerable refinement, yet not all those who administer the treatment are fully conversant with this. This paper addresses issues relating to electrode placement, stimulus dosing and seizure monitoring from practical and clinical points of view. Right unilateral ECT, if administered with high electrical stimulus, produces results close to bilateral treatment with substantially less cognitive impairment. However, certain patients may only respond to bilateral ECT. Adequate training for clinicians administering ECT is recommended.

A comparison of propofol and methohexital as anesthetic agents for ECT: effects on seizure duration, therapeutic outcome, and memory

The effects of the anesthetic agents propofol and methohexital on seizure duration, clinical outcome, recovery, and memory in electroconvulsive therapy (ECT) were studied in a double-blind trial. The study comprised 53 patients, 47 patients with major depression and six patients with other diagnoses according to DSM-III. Several recent clinical studies with a crossover design have shown a reduced seizure duration for anesthesia with propofol in comparison with both methohexital and thiopental. Propofol significantly reduced the seizure duration in this study without reducing the therapeutic outcome as measured by the Montgomery-Asberg Depression Rating Scale. Propofol did not significantly alter the length of the course of ECT; however, a slightly prolonged course for women cannot be completely ruled out. There were no significant differences between the two agents in effects on recovery times after anesthesia and on anterograde memory. In general, it seems that propofol is as effective as methohexital as an induction agent for ECT.

ECT emergence agitation and methohexital-succinylcholine interaction. Case report

Two separate methods of preventing post-ECT emergence agitation are increasing the succinylcholine dose to about 1.1 mg/kg and adding a methohexital bolus of about 0.67 mg/kg immediately at seizure end. These methods can work separately and additively without any expectation of diminishing treatment efficacy. A relevant case is described.

The onset and rate of the antidepressant effect of electroconvulsive therapy. A neglected topic of research

This annotation is concerned with how soon and at what rate antidepressant effects become apparent over a course of electroconvulsive therapy (ECT). The first question is of importance in the design and interpretation of biological studies of the mode of action of ECT. The second question is of practical interest to the treating psychiatrist when we ask how the speed of recovery is influenced by what the psychiatrist prescribes, that is, the number and frequency of treatments. These questions are little better answered now than 20 years ago. This may come as a surprise to many readers, who have been advised to use ECT when “seeking rapid improvement” in depressive disorders (ECT Sub-Committee of the Research Committee of the Royal College of Psychiatrists, 1989). This lack of progress is attributable to a dearth of appropriately designed ECT studies.

Electroconvulsive stimuli and brain peptides: effect of modification of seizure duration on neuropeptide Y, neurokinin A, substance P and neurotensin

We studied the effects of modification of duration of seizures induced by electroconvulsive stimuli (ECS) on the changes in concentration of neuropeptide Y (NPY), neurokinin A (NKA), substance P (SP) and neurotensin (NT)-like immunoreactivity (-LI) in specific rat brain regions. Rats were divided into groups pretreated with saline, indomethacin, flurbiprofen or diazepam prior to either six sham ECSs or six ECSs. After sacrifice by focused microwave irradiation, brains were dissected into frontal cortex, occipital cortex, striatum, hippocampus, pituitary and hypothalamic sections. Peptides were extracted and measured in extract aliquots by specific radioimmunoassays. Repeated ECS increased NPY-LI and NKA-LI in the hippocampus and the occipital cortex. No effect on SP-LI or NT-LI was found. Indomethacin and flurbiprofen had no effect on the tonic seizure time following ECS, and they did not affect the ECS-induced alterations of the brain peptides. Diazepam pretreatment decreased the tonic seizure time following ECS in a dose-dependent manner. However, diazepam did not modify the ECS-induced increase in NPY-LI and NKA-LI concentrations. The results firmly establish that ECS leads to specific peptide increases in discrete rat brain regions and raise the possibility that such changes may not entirely be a consequence of seizures per se.

Do benzodiazepines interfere with the action of electroconvulsive therapy?

A 67-year-old anxious and depressed woman was withdrawn from a long-term course of a benzodiazepine and soon after was given ECT. This proved ineffective, but ECT given some months later was successful. It is suggested that the chronic administration of the benzodiazepine may have induced changes in the brain that interfered with ECT.

A review of evidence for GABergic predominance/glutamatergic deficit as a common etiological factor in both schizophrenia and affective psychoses: more support for a continuum hypothesis of "functional" psychosis

Virtually all antidepressant and antipsychotic drugs, including clozapine, rimcazole and lithium ion, are proconvulsants, and convulsive therapy, using metrazol, a known GABA-A antagonist, as well as electro-convulsive therapy, can be effective in treating both schizophrenia and affective psychoses. Many antidepressant and antipsychotic drugs, including clozapine, as well as some of their metabolites, reverse the inhibitory effect of GABA on 35S-TBPS binding, a reliable predictor of GABA-A receptor blockade. A review of relevant literature suggests that 1) "functional" psychoses constitute a continuum of disorders ranging from schizophrenia to affective psychoses with overlap of symptoms, heredity and treatments, 2) a weakening of GABergic inhibitory activity, or potentiation of counterbalancing glutamatergic neurotransmission, in the brain, may be involved in the therapeutic activities of both antidepressant and antipsychotic drugs, and 3) schizophrenia and the affective psychoses may be different expressions of the same underlying defect: GABergic preponderance/glutamatergic deficit. Schizophrenia and affective psychoses share the following: 1) several treatments are effective in both, 2) similar modes of inheritance, 3) congruent seasonal birth excesses, 4) enlarged cerebral ventricles and cerebellar vermian atrophy, 5) dexamethasone non-suppression. Both genetic and environmental factors are involved in both schizophrenia and affective psychoses, and several lines of evidence suggest that important environmental factors are neurotropic pathogens that selectively destroy glutamatergic neurons. One group of genes associated with psychoses may increase vulnerability to attack and destruction, by neurotropic pathogens, of excitatory glutamatergic neurons that counterbalance inhibitory GABergic neurons. A second group of genes may encode subunits of overactive GABA-A receptors, while a third group of genes may encode subunits of hypo-active glutamate receptors. Improved antipsychotic drugs may be found among selective blockers of GABA-A receptor subtypes and/or enhancers of glutamatergic neurotransmission. A mechanism similar to kindling, leading to long-lasting reduction of GABergic inhibition in the brain, may be involved in several treatments of psychoses.

Antidepressant drug treatment in relation to the use of ECT

The adequacy of antidepressant treatment by psychiatrists prior to ECT was examined in a group of 95 patients. ECT was considered inevitable in 16 cases. Of the remainder, 41 patients had not been given adequate antidepressant treatment prior to ECT. Alternative drug strategies were seldom pursued after one drug had failed. Most patients were continued on a variety of psychotropic drugs during ECT. Subsequent outcome was poor, which may reflect difficulty in identifying an appropriate drug for continuation treatment after ECT.