Retrospective comparison of effectiveness of right unilateral ultra-brief pulse with brief pulse ECT in older adults (over 65) with depression

BACKGROUND

To compare response, remission and switch (to other pulse width and/or electrode placement) rates and number of treatments between groups receiving right unilateral ultra-brief (RUL-UB), Bitemporal brief (BT), Bifrontal Brief (BF) and Right unilateral brief (RUL-B).

METHOD

Data was collected from case notes in three centers. There were 133 in total, grouped as RUL-UB (50), BT (43), BF (23), RUL-B (17). Two of the three centers had a preferred electrode placement and pulse width.

RESULTS

Apart from age, the groups did not differ significantly on sex distribution, proportion of bipolar depression and psychotic symptoms. 56% of patients in RUL-UB switched compared to 12.5% in RUL-B, 4.9% in BT and none in BF (p value < 0.0001). When we considered patients who switched as treatment failures, remission rates were significantly different (p value < 0.0001) 40% in RUL-UB, 81.3% in RUL-B, 73.9% in BF and 78.0% in BT. Mean number of treatments in each group was significantly different (p value < 0.0001); 12.02 in RUL-UB, 10.2 in RUL-B, 7 in BF and 7.5 in BT. Post-hoc analysis indicated that RUL-UB differed significantly from BT and BF. Final response and remission rates including patients who switched were 98% and 82% in RUL-UB, 100% and 93.8% in RUL-B, 100% and 73.9% in BF and 97.7% and 83.7% in BT.

CONCLUSION

Majority commencing RUL-UB switched and received 4-5 more treatments compared to bilateral placements. RUL-UB ECT appears less effective and might not be appropriate as first line for all older adults as some patients at higher anaesthetic risk would benefit from having reduced number of treatments.

Development and validation of an improved neurological hemifield test to identify chiasmal and postchiasmal lesions by automated perimetry

PURPOSE

To improve the neurological hemifield test (NHT) using visual field data from both eyes to detect and classify visual field loss caused by chiasmal or postchiasmal lesions.

METHODS

Visual field and clinical data for 633 patients were divided into a training set (474 cases) and a validation set (159 cases). Each set had equal numbers of neurological, glaucoma, or glaucoma suspect cases, matched for age and for mean deviation between neurological and glaucoma cases. NHT scores as previously described and a new NHT laterality score were calculated. The ability of these scores to distinguish neurological from other fields was assessed with receiver operating characteristic (ROC) analysis. Three machine classifier algorithms were also evaluated: decision tree, random forest, and least absolute shrinkage and selection operator (LASSO). We also evaluated the ability of NHT to identify the type of neurological field defect (homonymous or bitemporal).

RESULTS

The area under the ROC curve (AUC) for the maximum NHT score was 0.92 (confidence interval [CI]: 0.87, 0.97). Using NHT laterality scores from each eye combined with the sum of NHT scores, the AUC improved to 0.93 (CI: 0.88, 0.98). The largest AUC for machine learning algorithms was for the LASSO method (0.96, CI: 0.92, 0.99). The NHT scores identified the type of neurological defect in 96% (158/164) of patients.

CONCLUSIONS

The new NHT distinguished neurological field defects from those of glaucoma and glaucoma suspects, providing accurate categorization of defect type. Its implementation may identify unsuspected neurological disease in clinical visual field testing.

Seizure duration decreases over a course of bifrontal and not bitemporal electroconvulsive therapy

CONTEXT

Mechanism of action of electroconvulsive therapy (ECT) is unclear. Anticonvulsant action of ECT has also been one among the hypothesized mechanisms. Anticonvulsant effect may manifest during ECT in at least two ways (a) increased seizure threshold (b) decrease in seizure duration. In depression, increased seizure threshold has been shown to be associated with better antidepressant response. However, relationship between seizure duration and antidepressant activity has been inconsistent. These issues are not investigated in conditions other than depression.

AIMS

We examined seizure duration over the course of ECT in schizophrenia patients.

SETTINGS AND DESIGN

Material for this analysis was obtained from a clinical trial examining the differential efficacy of bifrontal ECT (BFECT) versus bitemporal ECT (BTECT) in schizophrenia patients. As a part of study 122 schizophrenia patients who were prescribed ECT were randomized to receive either BFECT or BTECT.

SUBJECTS AND METHODS

Final analysis was conducted on data from 70 patients, as the rest of the data either had artifact or there was a significant change in medication status. Electroencephalogram seizure duration was noted in each session for these patients.

RESULTS

Seizure duration declined significantly from second ECT to 6(th) ECT (repeated measures analysis of variance F = 4.255; P = 0.006). When separate analysis was conducted for BTECT and BFECT patients the decline in seizure duration from 2(nd) to 6(th) ECT was significant only with BFECT (F = 3.94; P = 0.014) and not with BTECT (F = 0.966; P = 0.424).

CONCLUSIONS

Better anticonvulsant effects with BFECT may explain the better therapeutic observed with BFECT in schizophrenia as well as mania in our earlier studies.

Effectiveness of Bifrontal ECT in Practice: A Comparison with Bitemporal ECT

BACKGROUND

Bifrontal (BF) placement of electrodes in electroconvulsive therapy (ECT) has emerged as an alternative option to the conventional bitemporal (BT) and right unilateral electrode placement in view of fewer cognitive adverse effects. However, the results have been contradictory in terms of clinical efficacy.

MATERIALS AND METHODS

We studied the records of all patients referred for ECT between the months of August 2008 and July 2010 (n=1575). One hundred and five of these patients had received BF-ECT. These records were compared with the records of 105 patients who received BT-ECT. For each patient who received BF-ECT, the very next person posted for BT-ECT was taken as the control. All patients received bilateral ECTs at 1.5-times the threshold stimulus dose. The number of ECTs administered, duration of hospital stay after ECT initiation, seizure threshold and failure to achieve adequate seizures were compared. Two raters who achieved good inter-rater reliability assessed the initial severity using the clinical global impression scale and clinical improvement using a Likert scale.

RESULTS

The speed of response, as assessed by the number of ECTs received and the duration of hospital stay after ECT initiation was similar in the two groups. In addition, both groups were comparable in terms of clinical improvement scores on the Likert scale. BF-ECT patients also had a significantly higher seizure threshold, which remained significant in spite of controlling for age. This study is chart based, with its inherent limitations. Standard outcome measures were not used. Cognitive adverse effects were not studied.

CONCLUSIONS

BF-ECT performed similar to BT-ECT with regard to therapeutic efficacy. Given the consistent results of the former, with fewer cognitive side-effects, the findings of the present study support BF-ECT as the first line for electrode application.