Despite ongoing controversy, there has never been a large-scale, prospective study of the cognitive effects of electroconvulsive therapy (ECT). We conducted a prospective, naturalistic, longitudinal ...study of clinical and cognitive outcomes in patients with major depression treated at seven facilities in the New York City metropolitan area. Of 751 patients referred for ECT with a provisional diagnosis of a depressive disorder, 347 patients were eligible and participated in at least one post-ECT outcome evaluation. The primary outcome measures, Modified Mini-Mental State exam scores, delayed recall scores from the Buschke Selective Reminding Test, and retrograde amnesia scores from the Columbia University Autobiographical Memory Interview-SF (AMI-SF), were evaluated shortly following the ECT course and 6 months later. A substantial number of secondary cognitive measures were also administered. The seven sites differed significantly in cognitive outcomes both immediately and 6 months following ECT, even when controlling for patient characteristics. Electrical waveform and electrode placement had marked cognitive effects. Sine wave stimulation resulted in pronounced slowing of reaction time, both immediately and 6 months following ECT. Bilateral (BL) ECT resulted in more severe and persisting retrograde amnesia than right unilateral ECT. Advancing age, lower premorbid intellectual function, and female gender were associated with greater cognitive deficits. Thus, adverse cognitive effects were detected 6 months following the acute treatment course. Cognitive outcomes varied across treatment facilities and differences in ECT technique largely accounted for these differences. Sine wave stimulation and BL electrode placement resulted in more severe and persistent deficits.
Background Although electroconvulsive therapy (ECT) in major depression is effective, cognitive effects limit its use. Reducing the width of the electrical pulse and by using the right unilateral ...electrode placement may decrease adverse cognitive effects, while preserving efficacy. Methods In a double-masked study, we randomly assigned 90 depressed patients to right unilateral ECT at 6 times seizure threshold or bilateral ECT at 2.5 times seizure threshold, using either a traditional brief pulse (1.5 milliseconds) or an ultrabrief pulse (0.3 millisecond). Depressive symptoms and cognition were assessed before, during, and immediately, 2, and 6 months after therapy. Patients who responded were monitored for a 1-year period. Results The final remission rate for ultrabrief bilateral ECT was 35%, compared with 73% for ultrabrief unilateral ECT, 65% for standard pulse width bilateral ECT, and 59% for standard pulse width unilateral ECT (all P < .05 after covariate adjustment). The ultrabrief right unilateral group had less severe cognitive side effects than the other three groups in virtually all primary outcome measures assessed in the acute postictal period, and during and immediately after therapy. Both the ultrabrief stimulus and right unilateral electrode placement produced less short- and long-term retrograde amnesia. Patients rated their memory deficits as less severe after ultrabrief right unilateral ECT compared with each of the other three conditions ( P < .001). Conclusions The use of an ultrabrief stimulus markedly reduces adverse cognitive effects, and when coupled with markedly suprathreshold right unilateral ECT, also preserves efficacy. ( ClinicalTrials.gov number, NCT00487500.)
The concept of inducing convulsions, mainly through chemical means, to promote mental wellness has existed since the 16th century. In 1938, Italian scientists first applied electrically induced ...therapeutic seizures. Although electroconvulsive therapy (ECT) is employed in the treatment of several psychiatric disorders, it is most frequently used today to treat severe depressive episodes and remains the most effective treatment available for those disorders. Despite this, ECT continues to be the most stigmatized treatment available in psychiatry, resulting in restrictions on and reduced accessibility to a helpful and potentially life-saving treatment. The psychiatric and psychosocial ramifications of this stigmatization may include the exacerbation of the increasingly serious, global health problem of major depressive disorders as well as serious consequences for individual patients who may not be offered, or may refuse, a potentially beneficial treatment. The goal of this first article in this two-part series is to provide an overview of ECT's historical development and discuss the current state of knowledge about ECT, including technical aspects of delivery, patient selection, its side-effect profile, and factors that may contribute to underuse of ECT.
Abstract Although electroconvulsive therapy (ECT) remains the most effective treatment for severe depression, some patients report persistent memory problems following ECT that impact their quality ...of life and their willingness to consent to further ECT. While cognitive training has been shown to improve memory performance in various conditions, this approach has never been applied to help patients regain their memory after ECT. In a double-blind study, we tested the efficacy of a new cognitive training program called Memory Training for ECT (Mem-ECT), specifically designed to target anterograde and retrograde memory that can be compromised following ECT. Fifty-nine patients with treatment-resistant depression scheduled to undergo ultra-brief right unilateral ECT were randomly assigned to either: (a) Mem-ECT, (b) active control comprised of nonspecific mental stimulation, or (c) treatment as usual. Participants were evaluated within one week prior to the start of ECT and then again within 2 weeks following the last ECT session. All three groups improved in global function, quality of life, depression, and self-reported memory abilities without significant group differences. While there was a decline in verbal delayed recall and mental status, there was no decline in general retrograde memory or autobiographical memory in any of the groups, with no significant memory or clinical benefit for the Mem-ECT or active control conditions compared to treatment as usual. While we report negative findings, these results continue to promote the much needed discussion on developing effective strategies to minimize the adverse memory side effects of ECT, in hopes it will make ECT a better and more easily tolerated treatment for patients with severe depression who need this therapeutic option.
Increased gray matter volume (GMV) following electroconvulsive therapy (ECT) has been well-documented, with limited studies reporting a subsequent decrease in GMV afterwards.
This study characterized ...the reversion pattern of GMV after ECT and its association with clinical depression outcome, using multi-site triple time-point data from the Global ECT-MRI Research Collaboration (GEMRIC).
86 subjects from the GEMRIC database were included, and GMV in 84 regions-of-interest (ROI) was obtained from automatic segmentation of T1 MRI images at three timepoints: pre-ECT (T0), within one-week post-ECT (T1), and one to six months post-ECT (T2). RM-ANOVAs were used to assess longitudinal changes and LMM analyses explored associations between GMV changes and demographical and clinical characteristics.
63 of the 84 ROIs showed a significant increase-and-decrease pattern (RM-ANOVA, Bonferroni corrected p < 0.00059). Post hoc tests indicated a consistent pattern in each of these 63 ROIs: significant increase from T0 to T1inGMV, followed by significant decrease from T1 to T2 and no difference between T0 and T2, except for both amygdalae, right hippocampus and pars triangularis, which showed the same increase and decrease but GMV at T2 remained higher compared to T0. No consistent relationship was found between GMV change pattern and clinical status.
The GEMRIC cohort confirmed a rapid increase of GMV after ECT followed by reversion of GMV one to six months thereafter. The lack of association between the GMV change pattern and depression outcome scores implies a transient neurobiological effect of ECT unrelated to clinical improvement.
•A mega-analysis of longitudinal T1-weighted MRI data of patients receiving ECT from eight different sites was performed.•A pattern of gray matter volume (GMV) increase during ECT and a subsequent decrease one to six months thereafter was observed.•Four regions – associated with cognition and emotions – showed sustained higher GMV at one to six months after the ECT-course.•The pattern of GMV change did not correspond with clinical improvement after ECT.
We examined whether electroconvulsive therapy (ECT) plus medications (“STABLE + PHARM” group) had superior HRQOL compared with medications alone (“PHARM” group) as continuation strategy after ...successful acute right unilateral ECT for major depressive disorder (MDD). We hypothesized that scores from the Medical Outcomes Study Short Form-36 (SF-36) would be higher during continuation treatment in the “STABLE + PHARM” group versus the “PHARM” group. The overall study design was called “Prolonging Remission in Depressed Elderly” (PRIDE). Remitters to the acute course of ECT were re-consented to enter a 6 month RCT of “STABLE + PHARM” versus “PHARM”. Measures of depressive symptoms and cognitive function were completed by blind raters; SF-36 measurements were patient self-report every 4 weeks.
Participants were 120 patients >60 years old. Patients with dementia, schizophrenia, bipolar disorder, or substance abuse were excluded. The “PHARM” group received venlafaxine and lithium. The “STABLE + PHARM” received the same medications, plus 4 weekly outpatient ECT sessions, with additional ECT session as needed. Participants were mostly female (61.7%) with a mean age of 70.5 ± 7.2 years. “STABLE + PHARM” patients received 4.5 ± 2.5 ECT sessions during Phase 2. “STABLE + PHARM” group had 7 point advantage (3.5–10.4, 95% CI) for Physical Component Score of SF-36 (P < 0.0001), and 8.2 point advantage (4.2–12.2, 95% CI) for Mental Component Score (P < 0.0001). Additional ECT resulted in overall net health benefit. Consideration should be given to administration of additional ECT to prevent relapse during the continuation phase of treatment of MDD.
NCT01028508
Electroconvulsive therapy (ECT) technique is often changed after insufficient improvement, yet there has been little research on switching strategies.
To document clinical outcome in ECT ...nonresponders who were received a second course using high dose, brief pulse, bifrontotemporal (HD BP BL) ECT, and compare relapse rates and cognitive effects relative to patients who received only one ECT course and as a function of the type of ECT first received.
Patients were classified as receiving Weak, Strong, or HD BP BL ECT during three randomized trials at Columbia University. Nonresponders received HD BP BL ECT. In a separate multi-site trial, Optimization of ECT, patients were randomized to right unilateral or BL ECT and nonresponders also received further treatment with HD BP BL ECT.
Remission rates with a second course of HD BP BL ECT were high in ECT nonresponders, approximately 60% and 40% in the Columbia University and Optimization of ECT studies, respectively. Clinical outcome was independent of the type of ECT first received. A second course with HD BP BL ECT resulted in greater retrograde amnesia immediately, two months, and six months following ECT.
In the largest samples of ECT nonresponders studied to date, a second course of ECT had marked antidepressant effects. Since the therapeutic effects were independent of the technique first administered, it is possible that many patients may benefit simply from longer courses of ECT. Randomized trials are needed to determine whether, when, and how to change treatment technique in ECT.
•In two samples, a second course of ECT resulted in remarkably high remission rates after nonresponse to a full first course.•Clinical outcome following the second course, using high dose bilateral ECT, was independent of the type of ECT first used.•A second ECT course of produced more severe long-term retrograde amnesia for autobiographical information.•Many patients may need longer ECT courses to show clinical benefit.•Randomized trials are needed to test optimal methods for when and how to change ECT treatment technique.
Clinical trials indicate that electroconvulsive therapy (ECT) is the most effective treatment for major depression, but its effectiveness in community settings has not been examined.
In a ...prospective, naturalistic study involving 347 patients at seven hospitals, clinical outcomes immediately after ECT and over a 24-week follow-up period were examined in relation to patient characteristics and treatment variables.
The sites differed markedly in patient features and ECT administration but did not differ in clinical outcomes. In contrast to the 70%–90% remission rates expected with ECT, remission rates, depending on criteria, were 30.3%–46.7%. Longer episode duration, comorbid personality disorder, and schizoaffective disorder were associated with poorer outcome. Among remitters, the relapse rate during follow-up was 64.3%. Relapse was more frequent in patients with psychotic depression or comorbid Axis I or Axis II disorders. Only 23.4% of ECT nonremitters had sustained remission during follow-up.
The remission rate with ECT in community settings is substantially less than that in clinical trials. Providers frequently end the ECT course with the view that patients have benefited fully, yet formal assessment shows significant residual symptoms. Patients who do not remit with ECT have a poor prognosis; this underscores the need to achieve maximal improvement with this modality.
The myths surrounding electroconvulsive therapy (ECT) and the misconceptions held by the general public, clinicians, and patients have interfered with acceptance of this treatment throughout its ...history. Misunderstandings surrounding ECT, and its consequent stigmatization, are reviewed, including negative depictions of ECT in film, print media, and on the Internet. Clinicians involved in the delivery of ECT benefit from gaining an understanding of how ECT may be perceived by patients and other mental health professionals; they can play a vital role in educating patients and helping ensure the delivery of a successful course of ECT. Guidance is provided for clinicians on how to support patients and families through the ECT process using a model team approach. Anxiety reduction, meeting individual needs, patient and family psychoeducation, assessment of psychosocial supports, and discharge planning are discussed.
To determine whether starting antidepressant medication at the start of electroconvulsive therapy (ECT) reduces post-ECT relapse and to determine whether continuation pharmacotherapy with ...nortriptyline (NT) and lithium (Li) differs in efficacy or adverse effects from continuation pharmacotherapy with venlafaxine (VEN) and Li.
During an acute ECT phase, 319 patients were randomized to treatment with moderate dosage bilateral ECT or high-dosage right unilateral ECT. They were also randomized to concurrent treatment with placebo, NT, or VEN. Of 181 patients to meet post-ECT remission criteria, 122 (67.4%) participated in a second continuation pharmacotherapy phase. Patients earlier randomized to NT or VEN continued on the antidepressant, whereas patients earlier randomized to placebo were now randomized to NT or VEN. Lithium was added for all patients who were followed until relapse or 6 months.
Starting an antidepressant medication at the beginning of the ECT course did not affect the rate or timing of relapse relative to starting pharmacotherapy after ECT completion. The combination of NT and Li did not differ from VEN and Li in any relapse or adverse effect measure. Older age was strongly associated with lower relapse risk, whereas the type of ECT administered in the acute phase and medication resistance were not predictive. Across sites, 50% of the patients relapsed, 33.6% continued in remission 6 months after ECT, and 16.4% dropped out.
Starting an antidepressant medication during ECT does not affect relapse, and there are concerns about administering Li during an acute ECT course. Nortriptyline and VEN were equally effective in prolonging remission, although relapse rates after ECT are substantial despite intensive pharmacology. As opposed to the usual abrupt cessation of ECT, the impact of an ECT taper should be evaluated.
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