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Dai X, Zhang R, Deng N, Tang L, Zhao B. Anesthetic Influence on Electroconvulsive Therapy: A Comprehensive Review. Neuropsychiatr Dis Treat 2024; 20:1491-1502. [PMID: 39100572 PMCID: PMC11298179 DOI: 10.2147/ndt.s467695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 07/23/2024] [Indexed: 08/06/2024] Open
Abstract
The prevalence of severe mental disorders has been rising annually. Electroconvulsive therapy (ECT) is considered a valuable treatment option in psychiatry for conditions such as schizophrenia and medication-resistant depression, especially when other treatments have proven insufficient. ECT rapidly improves patients' mood, alleviates symptoms, and demonstrates significant therapeutic effects. Currently, the form of ECT used in clinical practice is modified electroconvulsive therapy (mECT), which is administered under general anesthesia. Accumulative evidence has confirmed that different anesthetic drugs, anesthetic-ECT time interval, anesthetic depth, and airway management can impact the outcomes of ECT. Therefore, this review aims to summarize the current impact of anesthesia factors on ECT, providing reference for clinical anesthesia during ECT procedures.
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Affiliation(s)
- Xinyu Dai
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Rui Zhang
- Department of Neurosurgery, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Nan Deng
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Le Tang
- Department of Psychiatry, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Bangshu Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
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Isenberg K, Dinwiddie SH, Song J, North CS. A Retrospective Matched Comparison Study of Prolonged Seizures in ECT. J ECT 2024; 40:37-40. [PMID: 37530874 DOI: 10.1097/yct.0000000000000951] [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: 08/03/2023]
Abstract
OBJECTIVE This study assessed the incidence of and risk factors for prolonged seizures (>180 sec) in electroconvulsive therapy (ECT). METHOD In 611 adult patients undergoing 6697 ECT treatments administered over a 2.5-year study period, 29 individuals experienced 42 prolonged seizures. A comparison sample (n = 29) was matched on sex, age, and treatment, and compared on psychiatric and medical diagnoses, as well as current medications. To examine the association between the characteristics and prolonged seizure, conditional logistic regression models or exact McNemar tests were conducted. RESULTS Prolonged seizures occurred on average in 1 of every 167 treatments. No specific psychiatric disorders or medical conditions were associated with the prolonged seizure group. Antipsychotic drugs were used in a higher proportion of the comparison group than in the prolonged seizure group, suggesting a protective effect. Atropine was used in a lower proportion of the long seizure group than in the comparison group. No untoward sequelae occurred, and no progression to status epilepticus was observed. CONCLUSIONS Prolonged seizures appear to be an uncommon complication of ECT in adults. The characteristics examined in this study suggest limited association of psychotropic medications with prolonged seizures. Treatment of prolonged seizures was straightforward. Prolonged seizures had no impact on the course of treatment. Further exploration of prolonged seizures would enhance the generalizability of the findings from this single site study.
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Affiliation(s)
| | | | - Jing Song
- Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Ren L, Yu J, Zeng J, Wei K, Li P, Luo J, Shen Y, Lv F, Min S. Comparative efficacy and tolerability of different anesthetics in electroconvulsive therapy for major depressive disorder: A systematic review and network meta-analysis. J Psychiatr Res 2024; 171:116-125. [PMID: 38271762 DOI: 10.1016/j.jpsychires.2024.01.031] [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: 09/11/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 01/27/2024]
Abstract
Electroconvulsive therapy (ECT) is one of the most effective treatments for major depressive disorder. Modern ECT is conducted with anesthesia, however, the optimal anesthetic agent for ECT is yet to be understood. This study is aimed to compare the effects of different anesthetic agents on antidepressant efficacy and tolerability in depressed individuals undergoing ECT. We searched MEDLINE, EMBASE, the CENTRAL and PsycINFO for randomized controlled trials from database inception until Nov 13, 2022 (PROSPERO: CRD42022375407). Global and local inconsistencies, heterogeneity and publication bias were assessed. Rankings were calculated with the surface under the cumulative ranking curve. A total of 33 studies involving 1898 patients were enrolled. Remission rates were higher for ketamine anesthesia as compared to adjunctive ketamine and propofol. In terms of ranking, ketamine was found to be first in terms of response/remission rates and depressive scores after the 1st, 3rd and 6th ECT and at the end of ECT session, while a higher incidence of adverse events was also observed. No significant advantage of any anesthetic was revealed for the cognitive function after ECT. In summary, based on current evidence, no specific anesthetic is recommended for ECT anesthesia. However, despite more side effects, ketamine monoanesthesia seems to reveal a potential benefit in improving antidepressant efficacy of ECT, and further studies are needed to investigate the relationship between anesthetic agents and the therapeutic effect of ECT.
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Affiliation(s)
- Li Ren
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian Yu
- Department of Psychiatry, Shanghai Tenth People's Hospital, Anesthesia and Brain Research Institute, Tongji University, Shanghai, China
| | - Jie Zeng
- Department of Anesthesiology, Stomatological Hospital of Chongqing Medical University, Chongqing, China
| | - Ke Wei
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ping Li
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Luo
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yiwei Shen
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Lv
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Rodolico A, Cutrufelli P, Di Francesco A, Aguglia A, Catania G, Concerto C, Cuomo A, Fagiolini A, Lanza G, Mineo L, Natale A, Rapisarda L, Petralia A, Signorelli MS, Aguglia E. Efficacy and safety of ketamine and esketamine for unipolar and bipolar depression: an overview of systematic reviews with meta-analysis. Front Psychiatry 2024; 15:1325399. [PMID: 38362031 PMCID: PMC10867194 DOI: 10.3389/fpsyt.2024.1325399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 01/03/2024] [Indexed: 02/17/2024] Open
Abstract
Background Unipolar and bipolar depression present treatment challenges, with patients sometimes showing limited or no response to standard medications. Ketamine and its enantiomer, esketamine, offer promising alternative treatments that can quickly relieve suicidal thoughts. This Overview of Reviews (OoR) analyzed and synthesized systematic reviews (SRs) with meta-analysis on randomized clinical trials (RCTs) involving ketamine in various formulations (intravenous, intramuscular, intranasal, subcutaneous) for patients with unipolar or bipolar depression. We evaluated the efficacy and safety of ketamine and esketamine in treating major depressive episodes across various forms, including unipolar, bipolar, treatment-resistant, and non-resistant depression, in patient populations with and without suicidal ideation, aiming to comprehensively assess their therapeutic potential and safety profile. Methods Following PRIOR guidelines, this OoR's protocol was registered on Implasy (ID:202150049). Searches in PubMed, Scopus, Cochrane Library, and Epistemonikos focused on English-language meta-analyses of RCTs of ketamine or esketamine, as monotherapy or add-on, evaluating outcomes like suicide risk, depressive symptoms, relapse, response rates, and side effects. We included studies involving both suicidal and non-suicidal patients; all routes and formulations of administration (intravenous, intramuscular, intranasal) were considered, as well as all available comparisons with control interventions. We excluded meta-analysis in which the intervention was used as anesthesia for electroconvulsive therapy or with a randomized ascending dose design. The selection, data extraction, and quality assessment of studies were carried out by pairs of reviewers in a blinded manner. Data on efficacy, acceptability, and tolerability were extracted. Results Our analysis included 26 SRs and 44 RCTs, with 3,316 subjects. The intervention is effective and well-tolerated, although the quality of the included SRs and original studies is poor, resulting in low certainty of evidence. Limitations This study is limited by poor-quality SRs and original studies, resulting in low certainty of the evidence. Additionally, insufficient available data prevents differentiation between the effects of ketamine and esketamine in unipolar and bipolar depression. Conclusion While ketamine and esketamine show promising therapeutic potential, the current evidence suffers from low study quality. Enhanced methodological rigor in future research will allow for a more informed application of these interventions within the treatment guidelines for unipolar and bipolar depression. Systematic review registration [https://inplasy.com/inplasy-2021-5-0049/], identifier (INPLASY202150049).
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Affiliation(s)
- Alessandro Rodolico
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Pierfelice Cutrufelli
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Antonio Di Francesco
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gaetano Catania
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
- University of Catania, Catania, Italy
| | - Carmen Concerto
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Alessandro Cuomo
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
- Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Troina, Italy
| | - Ludovico Mineo
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Antimo Natale
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
- Department of Psychiatry, Adult Psychiatry Service (SPA), University Hospitals of Geneva (HUG), Geneva, Switzerland
| | - Laura Rapisarda
- Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania, Catania, Italy
| | - Antonino Petralia
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Maria Salvina Signorelli
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | - Eugenio Aguglia
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
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Methfessel I, Zilles-Wegner D, Kunze-Szikszay N, Belz M. Effects of Anesthesia Changes During Maintenance ECT: A Longitudinal Comparison of Seizure Quality Under Anesthesia Using Propofol/Esketamine Versus Methohexital. PHARMACOPSYCHIATRY 2023. [PMID: 37116539 DOI: 10.1055/a-2058-9010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
INTRODUCTION The effectiveness of ECT relies on the induction of a generalized cerebral seizure. Among others, seizure quality (SQ) is potentially influenced by the anesthetic drug used. Commonly used anesthetics comprise barbiturates, etomidate, propofol, and esketamine, with different characteristics and impacts on seizure parameters. So far, no studies have compared the influence of methohexital vs. a combination of propofol/esketamine on established SQ parameters. METHODS This retrospective longitudinal study compared eight established SQ parameters (PSI, ASEI, MSC, midictal amplitude, motor and electroencephalography (EEG) seizure duration, concordance, PHR) before and after the change from propofol/esketamine to methohexital in 34 patients under maintenance ECT. Each patient contributed four measurements, two before and two after the anesthesia change. Anesthesia dose, stimulus dose, electrode placement, and concomitant medication remained unchanged throughout the analyzed treatments. RESULTS Under methohexital (M=88.97 mg), ASEI (p=0.039 to 0.013) and midictal amplitude (p=0.022 to<0.001) were significantly lower, whereas seizure duration (motor and EEG) was significantly longer when compared to propofol/esketamine (M=64.26 mg/51.18 mg; p=0.012 to<0.001). PSI, MSC, seizure concordance, and PHR were not affected by the anesthetic used. DISCUSSION Although to what extent these parameters correlate with the therapeutic effectiveness remains ambiguous, a decision for or against a particular anesthetic could be considered if a specific SQ parameter needs optimization. However, no general superiority for one specific substance or combination was found in this study. In the next step, anesthetic effects on treatment response and tolerability should be focused on.
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Affiliation(s)
- Isabel Methfessel
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany
| | - David Zilles-Wegner
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany
| | - Nils Kunze-Szikszay
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Belz
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany
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Yatomi T, Uchida T, Takamiya A, Wada M, Kudo S, Nakajima K, Nishida H, Yamagata B, Mimura M, Hirano J. Impact of Sevoflurane and Thiopental Used Over the Course of Electroconvulsive Therapy: Propensity Score Matching Analysis. Front Hum Neurosci 2022; 16:933622. [PMID: 35880104 PMCID: PMC9308003 DOI: 10.3389/fnhum.2022.933622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/13/2022] [Indexed: 12/02/2022] Open
Abstract
Objective Although anesthetics play an important role in electroconvulsive therapy (ECT), the clinical efficacy and seizure adequacy of sevoflurane in the course of ECT remain unclear. The purpose of this study was to examine the clinical efficacy and seizure adequacy of sevoflurane, compared with those of thiopental, in the course of ECT in patients with mood disorders. Methods We conducted a retrospective chart review. Patients who underwent a course of ECT and received sevoflurane (n = 26) or thiopental (n = 26) were included. Factors associated with ECT and treatment outcomes were compared between the two groups using propensity score (PS) matching. Between-group differences were examined using an independent t-test for continuous variables and a χ2-test for categorical variables. Results Patients who received sevoflurane needed more stimulations (sevoflurane: 13.2 ± 4 times, thiopental: 10.0 ± 2.5 times, df = 51, p = 0.001) and sessions (sevoflurane: 10.0 ± 2.1 times, thiopental: 8.4 ± 2.1 times, df = 51, p = 0.01) and had more inadequate seizures (sevoflurane: 5 ± 3.9 times, thiopental: 2.7 ± 2.7 times, df = 51, p = 0.015). Remission and response rates were similar in both groups. Conclusion The present findings indicate that sevoflurane should be used with caution in ECT and only when the clinical rationale is clear.
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Affiliation(s)
- Taisuke Yatomi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Takahito Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
- Department of Psychiatry, Melbourne Neuropsychiatry Centre, The University of Melbourne, Parkville, VIC, Australia
| | - Akihiro Takamiya
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Masataka Wada
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kudo
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Kazuki Nakajima
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hana Nishida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Bun Yamagata
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Jinichi Hirano
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
- *Correspondence: Jinichi Hirano,
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The effects of anesthetic change on electrographic seizure duration during electroconvulsive therapy. Brain Stimul 2021; 14:1084-1086. [PMID: 34293513 DOI: 10.1016/j.brs.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/06/2021] [Accepted: 07/16/2021] [Indexed: 11/21/2022] Open
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Woolsey AJ, Nanji JA, Moreau C, Sivapalan S, Bourque SL, Ceccherini-Nelli A, Gragasin FS. Low-dose ketamine does not improve the speed of recovery from depression in electroconvulsive therapy: a randomized controlled trial. ACTA ACUST UNITED AC 2021; 44:6-14. [PMID: 34076068 PMCID: PMC8827368 DOI: 10.1590/1516-4446-2020-1705] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/17/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) is a well-established therapeutic intervention for major depressive disorder. Recent literature has shown that the anesthetic agent ketamine has some antidepressant properties at low doses and may be an alternative therapy for treatment-resistant major depressive disorder. We hypothesized that the use of low-dose ketamine as an anesthetic adjunct in ECT would more rapidly improve depression while maintaining hemodynamic stability than ECT with propofol alone. METHODS Institutional ethics approval was obtained, and the use of ketamine in this study was approved by Health Canada. This is a randomized, double-blinded, placebo-controlled trial that involved ketamine administration at 0.5 mg/kg IV in addition to propofol anesthesia for ECT. The primary outcome was the number of ECT treatments required to achieve a 50% reduction in the Montgomery-Asberg Depression Rating Scale (MADRS). Secondary outcomes included the number of ECT treatments required to achieve a 25% reduction in MADRS score, as well as any differences in the Clinical Global Impression Scale for Severity, hemodynamic variables, and seizure duration. Adverse events were recorded for safety assessment. RESULTS A total of 45 patients completed the study. No difference was found between groups with respect to the primary or secondary outcomes. The ketamine group showed a trend towards a decreased dose of propofol required to achieve adequate anesthesia. No adverse events were reported. CONCLUSION Low-dose ketamine does not improve psychiatric outcomes in the setting of propofol-based anesthesia for ECT. Specifically, ketamine did not reduce the number of ECT sessions necessary to achieve a 50 or 25% reduction in MADRS scores. Reassuringly, the fact that no differences in hemodynamic variables or unexpected adverse events occurred suggests that low-dose ketamine may be safely used in this setting should clinical indications warrant its use. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02579642.
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Affiliation(s)
- Adrianna J Woolsey
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jalal A Nanji
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Chantal Moreau
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Sudhakar Sivapalan
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Stephane L Bourque
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Ferrante S Gragasin
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
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de Arriba-Arnau A, Soria V, Salvat-Pujol N, Menchón JM, Urretavizcaya M. Similar clinical improvement of depression using 0.5-ms and 1-ms pulse widths in bilateral electroconvulsive therapy. Eur Arch Psychiatry Clin Neurosci 2021; 271:465-473. [PMID: 31832757 DOI: 10.1007/s00406-019-01089-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/23/2019] [Indexed: 01/26/2023]
Abstract
There is a lack of research regarding 0.5-ms pulse width (PW) in bilateral electroconvulsive therapy (ECT). The aim of this study was to compare the efficacy and number of treatment sessions between groups receiving 0.5-ms and 1-ms PW ECT. Ninety-four patients with unipolar major depression treated with acute bilateral ECT were analysed retrospectively, grouped as consecutive patients treated with 0.5-ms PW ECT (n = 47), and age- and sex-matched patients treated with 1-ms PW ECT. Clinical and ECT data were extracted from clinical records. Symptom evaluations and global cognitive screening at baseline and post-ECT were administered by trained psychiatrists. The Hamilton Rating Scale for Depression (HDRS-21) was rated weekly. Efficacy and number of treatment sessions were compared between groups. PW was explored as a predictor of mean decrease in HDRS and number of treatment sessions by regression models. Group characteristics did not differ at baseline. The mean decrease in HDRS in the 0.5- and 1-ms PW [25.85 (7.79) vs. 24.33 (6.99), respectively], response (95.7% vs. 97.9%), remission (87.2% vs. 80.9%) and mean number of treatment sessions [11.28 (3.85) vs. 11.34 (3.36)] were not significantly different. Episode duration and severity, and previous ECT predicted HDRS decrease. Severity at baseline and the 6th session, the dosing method and the last ECT treatment dose predicted the number of treatment sessions needed. PW was not significant in the regressions models. The results suggest that both PWs perform similarly in bilateral ECT for depression, resulting in equivalent antidepressant efficacy and number of treatment sessions needed.
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Affiliation(s)
- Aida de Arriba-Arnau
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL) Neurosciences Group - Psychiatry and Mental Health, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Madrid, Spain
| | - Virginia Soria
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL) Neurosciences Group - Psychiatry and Mental Health, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Madrid, Spain.,Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Neus Salvat-Pujol
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL) Neurosciences Group - Psychiatry and Mental Health, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Madrid, Spain
| | - José M Menchón
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL) Neurosciences Group - Psychiatry and Mental Health, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Madrid, Spain.,Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Mikel Urretavizcaya
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL) Neurosciences Group - Psychiatry and Mental Health, L'Hospitalet de Llobregat, Barcelona, Spain. .,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Madrid, Spain. .,Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain.
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İkiz C, Günenç F, İyilikçi L, Özbilgin Ş, Ellidokuz H, Cimilli C, Mermi Z, Gökel E. Effects of Propofol and Propofol-Remifentanil Combinations on Haemodynamics, Seizure Duration and Recovery during Electroconvulsive Therapy. Turk J Anaesthesiol Reanim 2021; 49:44-51. [PMID: 33718905 PMCID: PMC7932704 DOI: 10.5152/tjar.2020.157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 01/20/2020] [Indexed: 11/22/2022] Open
Abstract
Objective This study aimed to evaluate the effects of adding different doses of remifentanil to propofol treatment compared with propofol alone with regard to parameters, including the seizure duration, haemodynamic changes and recovery time, in patients undergoing electroconvulsive therapy (ECT). Methods This study was designed as a self-controlled, prospective, double-blind investigation of 17 patients between the ages of 20 and 65 years who had planned treatment with ECT at a psychiatric clinic. Group P (propofol) was administered 10 mL of normal saline after 0.5 mg kg−1 intravenous (IV) bolus of propofol. Group R I (propofol plus remifentanil-1) was administered 1.5 μg kg−1 of remifentanil, and group R II (propofol plus remifentanil-2) was given 2 μg kg−1 of remifentanil after 0.5 mg kg−1 IV bolus of propofol. The haemodynamic variables after seizure and the seizure duration were recorded. Time to return to spontaneous respiration, eye opening and achieving Aldrete score >9 were recorded. Results The electroencephalography seizure duration was significantly longer in groups R I (34.7±13 s) and R II (34.9±12) than in group P (24±7.5). Motor seizure duration was longer in groups R I (29.70±12.8) and R II (28.1±10) than in group P (21±7.3). The amount of total propofol was 121±21 mg in group P, 69.4±2 mg in group R I and 67±17 mg in group R II. Times to eye opening, following simple commands, and achieving Aldrete score >9 were significantly shorter in groups R I and R II than in group P. Conclusion ECT is a safe and effective treatment for patients with psychiatric disorders. Propofol-remifentanil anaesthesia prolongs the seizure duration and shortens the recovery time, suggesting that this combination may particularly be well suited for use in this patient group.
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Affiliation(s)
- Canan İkiz
- Department of Anaesthesiology and Intensive Care, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Ferim Günenç
- Department of Anaesthesiology and Intensive Care, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Leyla İyilikçi
- Department of Anaesthesiology and Intensive Care, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Şule Özbilgin
- Department of Anaesthesiology and Intensive Care, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Hülya Ellidokuz
- Department of Medical Informatics and Biostatistics, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Can Cimilli
- Department of Psychiatry, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Zehra Mermi
- Department of Anaesthesiology and Intensive Care, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Erol Gökel
- Department of Anaesthesiology and Intensive Care, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
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Tedeschi EA, Patusco LM, Zahler S, Martini M, Chiavaro da Fonseca R, Magalhães PVS. Factors Associated With Seizure Adequacy Along the Course of Electroconvulsive Therapy. J ECT 2021; 37:46-50. [PMID: 32881781 DOI: 10.1097/yct.0000000000000716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Eliciting a generalized seizure is essential to electroconvulsive therapy (ECT), but there is still a need to understand how patient and session variables interact to generate a seizure of adequate quality. Here, we investigate factors associated with motor seizure length as a measure of quality in a large database of patients who underwent ECT. METHODS This is a retrospective cohort including data from all adult inpatients who underwent ECT at a university hospital in Brazil from 2009 to 2015. We used linear mixed models to investigate the effects of patient, session, and medication on seizure length. RESULTS Session information was available for 387 patients, a total of 3544 sessions and 4167 individual stimulations. Multiple stimulations were necessary in 12.4% of sessions. Median seizure length was 30 seconds. Seizure length was directly correlated with stimulus dosage and inversely correlated with the session number, patient age, prescription of anticonvulsants in the day before and β-blockers during the session, and the thiopental dose. Use of benzodiazepines was not associated with a shorter seizure duration, irrespective of dose. CONCLUSIONS We demonstrate here how motor seizure length evolves during a course of ECT. With a large number of sessions, we are able to integrate a host of factors in a prediction model. Seizure quality was influenced by a number of the studied factors, many of which are potentially modifiable and could be assessed before initiating and handled during treatment.
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Affiliation(s)
- Eduardo Antonio Tedeschi
- From the Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Centro de Pesquisa Clínica, Graduate Program in Psychiatry and Behavioral Sciences, Porto Alegre, Brazil
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12
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Empirical ratio of the combined use of S-ketamine and propofol in electroconvulsive therapy and its impact on seizure quality. Eur Arch Psychiatry Clin Neurosci 2021; 271:457-463. [PMID: 32699969 PMCID: PMC7981301 DOI: 10.1007/s00406-020-01170-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/13/2020] [Indexed: 12/19/2022]
Abstract
Electroconvulsive therapy (ECT) is an effective treatment for depressive disorders. In certain cases, ECT-associated anaesthesia can be improved by the use of ketofol (i.e., S-ketamine + propofol). We aimed to evaluate the empirical mixing ratio of ketofol in these cases for better clinical implementation. We retrospectively investigated n = 52 patients who received 919 ECT sessions with S-ketamine plus propofol as anaesthetic agents. Several anaesthesia and ECT-related parameters including doses of S-ketamine and propofol were analysed. The mean empirically determined S-ketamine/propofol ratio was 1.38 (SD ± 0.57) for 919 individual ECT sessions and 1.52 (SD ± 0.62) for 52 patients, respectively. The mean relative dose was 0.72 (± 0.18) mg/kg S-ketamine and 0.54 (± 0.21) mg/kg propofol. Higher propofol dose was associated with poorer seizure quality. Seizure quality and time in recovery room were significantly influenced by age. Ketofol could be an option to exploit the advantageous qualities of S-ketamine and propofol, if both doses are reduced compared with single use of S-ketamine or propofol. Patients with poor seizure quality may benefit from lower propofol doses, which are applicable by the addition of ketamine. An empirically determined mixing ratio in favour of ketamine turned out to be preferable in a clinical setting. Recovery time was primarily prolonged by higher age rather than by ketamine dose, which had previously often been associated with a prolonged monitoring time in the recovery room. These new findings could improve electroconvulsive therapy and should be replicated in a prospective manner.
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Li XM, Shi ZM, Wang PJ, Hu H. Effects of ketamine in electroconvulsive therapy for major depressive disorder: meta-analysis of randomised controlled trials. Gen Psychiatr 2020; 33:e100117. [PMID: 32596639 PMCID: PMC7299006 DOI: 10.1136/gpsych-2019-100117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 03/30/2020] [Accepted: 04/16/2020] [Indexed: 01/20/2023] Open
Abstract
Background The use of ketamine in electroconvulsive therapy (ECT) has been examined in the treatment of major depressive disorder (MDD); however, there has been no systematic review and meta-analysis of related randomised controlled trials (RCTs). Aim To examine the efficacy and safety of ketamine augmentation of ECT in MDD treatment. Methods Two reviewers searched Chinese (China National Knowledge Infrastructure and Wanfang) and English (PubMed, PsycINFO, Embase and Cochrane Library) databases from their inception to 23 July 2019. The included studies' bias risk was evaluated using the Cochrane risk of bias assessment tool. The primary outcome of this meta-analysis was improved depressive symptoms at day 1 after a single ECT treatment session. Data were pooled to calculate the standardised mean difference and risk ratio with their 95% CIs using RevMan V.5.3. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to assess the whole quality of evidence. Results Four RCTs (n = 239) compared ketamine alone or ketamine plus propofol (n = 149) versus propofol alone (n = 90) in patients with MDD who underwent a single ECT session. Three RCTs were considered as unclear risk with respect to random sequence generation using the Cochrane risk of bias. Compared with propofol alone, ketamine alone and the combination of ketamine and propofol had greater efficacy in the treatment of depressive symptoms at days 1, 3 and 7 after a single ECT session. Moreover, compared with propofol alone, ketamine alone and the combination of ketamine and propofol were significantly associated with increased seizure duration and seizure energy index. Compared with propofol, ketamine alone was significantly associated with increased opening-eye time. Based on the GRADE approach, the evidence level of primary and secondary outcomes ranged from very low (26.7%, 4/15) to ‘low’ (73.3%, 11/15). Conclusion Compared with propofol, there were very low or low evidence levels showing that ketamine alone and the combination of ketamine and propofol appeared to rapidly improve depressive symptoms of patients with MDD undergoing a single ECT session. There is a need for high-quality RCTs.
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Affiliation(s)
- Xiao-Mei Li
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhan-Ming Shi
- Department of Psychiatry, Chongqing Jiangbei Mental Health Center, Chongqing, China
| | - Pei-Jia Wang
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hua Hu
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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14
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Pournajafian A, Faiz H, Motazedi Ghajar MA, Koleini ZS, Mohseni M. The effect of ketamine versus thiopental sodium on hemodynamic profile and seizure duration during electroconvulsive therapy in patients with major depressive disorder: A randomized cross-over clinical trial. Med J Islam Repub Iran 2020; 34:11. [PMID: 32551300 PMCID: PMC7293804 DOI: 10.34171/mjiri.34.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
Background: Electroconvulsive therapy (ECT) is an effective treatment in major depressive disorder (MDD). Earlier studies suggest that ketamine has antidepressive effects and prolongs seizure duration in favor of therapeutic efficacy of ECT. A great concern with the use of ketamine is its possible adverse hemodynamic effects during ECT. This study was conducted to compare the hemodynamic effect and seizure duration between ketamine and sodium thiopental, a common anesthetic in ECT. Methods: In a cross-over clinical trial, 26 patients of either sex with MDD who were candidates for ECT therapy in a university hospital were enrolled. A total of 13 patients received induction with ketamine in the first session and thiopental for the second. The sequence of treatments was vice versa in the other group. The followings were measured in all patients: blood pressure, heart rate, and oxygen saturation before induction, immediately after induction, at 1, 2, 4, and 10 minutes postinduction, and after recovery from anesthesia. Also, seizure duration, recovery time, and complications of treatments were measured. Chi square test and student t test were used for categorical data and numerical data, respectively. P values < 0.05 were considered statistically significant. Analyses were performed with SPSS software version 21.0. Results: Heart rate, systolic and diastolic blood pressure, oxygen saturation, and recovery time were comparable between groups. Mean duration of convulsion in patients who received ketamine was significantly more than those who received STP (36±11 vs 28±9 s, p=0.001). Myalgia was less common in patients who received ketamine rather than sodium thiopental (11.5 vs 46.2%, p=0.014). Conclusion: Ketamine prolongs seizure duration with no deleterious effects on hemodynamic parameters. Considering the antidepressant effects of ketamine, it may be a better choice, compared to thiopental sodium, for MDD patients.
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Affiliation(s)
- Alireza Pournajafian
- 1Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Faiz
- 1Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran
| | | | - Zahra Sadat Koleini
- 1Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran
| | - Masood Mohseni
- 1Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran
,Corresponding author: Dr Masood Mohseni,
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Modir H, Bahramsari S, Moshiri E, Jamilian H, Mohammadbeigi A. Comparing the premedication effects of dexmedetomidine, remifentanil and labetalol before electroconvulsive therapy on haemodynamic responses and seizure duration in psychotic patients: A double-blinded clinical trial. ADVANCES IN HUMAN BIOLOGY 2020. [DOI: 10.4103/aihb.aihb_121_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Corriger A, Pickering G. Ketamine and depression: a narrative review. DRUG DESIGN DEVELOPMENT AND THERAPY 2019; 13:3051-3067. [PMID: 31695324 PMCID: PMC6717708 DOI: 10.2147/dddt.s221437] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/01/2019] [Indexed: 12/20/2022]
Abstract
Depression is the third leading cause of disability in the world. Depressive symptoms may be reduced within several weeks after the start of conventional antidepressants, but treatment resistance concerns one-third of patients who fail to achieve recovery. Over the last 20 years, ketamine, an antagonist of the N-methyl-D-aspartate receptor, has been described to have antidepressant properties. A literature review was conducted through an exhaustive electronic search. It was restricted to Cochrane reviews, meta-analyses, and randomized controlled trials (RCTs) of ketamine for major depressive disorder and/or bipolar disorder. This review included two Cochrane reviews, 14 meta-analyses and 15 trials. Ketamine was studied versus placebo, versus other comparators and as an anesthetic adjuvant before electroconvulsive therapy. In 14 publications, ketamine provided a rapid antidepressant effect with a maximum efficacy reached at 24 hrs. Its effect lasted for 1–2 weeks after infusion, but a longer-term effect is little reported. Ketamine does not seem to improve depressive symptoms at the end of electroconvulsive sessions. Safety and tolerability profiles with ketamine at low single dose are generally good in depressed patients. However, there is a lack of data concerning ketamine with repeated administration at higher doses. The clinical use of ketamine is increasing. Intranasal (S)-ketamine has recently been approved for depression by the Food and Drug Administration. It could be a promising treatment in depressed patients with suicidal ideation. Collectively, the level of proof of efficacy remains low and more RCTs are needed to explore efficacy and safety issues of ketamine in depression.
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Affiliation(s)
- Alexandrine Corriger
- Neuro-Dol Laboratory Inserm 1107, Clermont Auvergne University, Clermont-Ferrand, France.,Clinical Pharmacology Department CPC/CIC Inserm 1405, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Gisèle Pickering
- Neuro-Dol Laboratory Inserm 1107, Clermont Auvergne University, Clermont-Ferrand, France.,Clinical Pharmacology Department CPC/CIC Inserm 1405, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
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17
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Mitra S, Mehta UM, Binukumar B, Venkatasubramanian G, Thirthalli J. Statistical power estimation in non-invasive brain stimulation studies and its clinical implications: An exploratory study of the meta-analyses. Asian J Psychiatr 2019; 44:29-34. [PMID: 31302440 PMCID: PMC7610509 DOI: 10.1016/j.ajp.2019.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/07/2019] [Accepted: 07/05/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Non-invasive brain stimulation (NIBS) techniques have emerged as a promising tool for understanding and treating psychiatric disorders, necessitating a caution in terms of interpreting research results. OBJECTIVE This study aimed at systematically evaluating a representative sample of research conducted using NIBS interventions in neuro-psychiatric conditions, and assessing the power these studies achieved, given their sample sizes. METHODS A database search was conducted with defined keyword combinations. Using reported summary effects of the meta-analyses as estimate of the true effects, we calculated achieved power of each individual study to detect the effect indicated by the corresponding meta-analysis. RESULTS Findings suggest that mean and median powers in the field of NIBS were 0.50, with a mode at 0.83 (range 0.05-1.00). When analysed separately, the median powers were 0.27 for tDCS, 0.70 for TMS and 0.97 for ECT. These studies had a mean total sample size of 22.2 ± 24.9 subjects and the median reported effect size across all studies was 0.61. CONCLUSION According to our findings, studies conducted in NIBS miss around 50% of true positive results. Further, it appears that most of the researchers in this field chase statistical significance with small sample sizes, thus compromising the quality of their conclusions.
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Affiliation(s)
- Sayantanava Mitra
- Central Queensland Mental Health, Alcohol and Other Drugs Services (CQMHAODS), Base Hospital, Rockhampton, Queensland, Australia; Faculty of Medicine, The University of Queensland Rural Clinical School, Rockhampton, Queensland, Australia.
| | - Urvakhsh Meherwan Mehta
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Bhaskarapillai Binukumar
- Department of Biostatistics, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Ganesan Venkatasubramanian
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Jagadisha Thirthalli
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
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18
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Zheng W, Li XH, Zhu XM, Cai DB, Yang XH, Ungvari GS, Ng CH, Ning YP, Hu YD, He SH, Wang G, Xiang YT. Adjunctive ketamine and electroconvulsive therapy for major depressive disorder: A meta-analysis of randomized controlled trials. J Affect Disord 2019; 250:123-131. [PMID: 30852364 DOI: 10.1016/j.jad.2019.02.044] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/14/2019] [Accepted: 02/16/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Adjunctive ketamine with electroconvulsive therapy (ECT) has been investigated for treating major depressive disorder (MDD), but the findings have been inconsistent. AIM This is an updated meta-analysis of the efficacy and safety of ketamine augmentation of ECT in the treatment of MDD. METHODS Randomized controlled trials (RCTs) reporting on the efficacy and safety of ketamine and ECT were identified and analyzed. RESULTS Seventeen RCTs (n = 1,035) compared ketamine alone or ketamine plus other anesthetic drugs (n = 557) with other anesthetic agents (n = 478) in MDD patients who received ECT. Ketamine+other anesthetic drugs was superior in improving depressive symptoms over other anesthetic medications at early study time point, but not at post-ECT or end of study time points. Ketamine alone was not more efficacious in treating depressive symptoms than other anesthetic drugs at early study, post-ECT and end of study time points. Sensitivity analysis and 19 of the 20 subgroup analyses also confirmed the lack of significance of these findings. Eleven RCTs testing the effects of ketamine on neurocognitive functions with various test batteries found mixed results. Ketamine alone significantly increased blood pressure more than other anesthetic drugs in MDD treated with ECT. CONCLUSION Compared to other anesthetic agents, ketamine alone does not appear to improve the efficacy of ECT. However, ketamine+other anesthetic combinations may confer a short-term advantage in improving depressive symptom at the early stages of ECT.
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Affiliation(s)
- Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Xiao-Hong Li
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital & The Advanced Innovation Center for Human Brain Protection, Capital Medical University, School of Mental Health, Beijing, China
| | - Xiao-Min Zhu
- Suzhou Guangji Hospital, The Affiliated Guangji Hospital of Soochow University, Suzhou, China
| | - Dong-Bin Cai
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Xin-Hu Yang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Gabor S Ungvari
- The University of Notre Dame Australia, Fremantle, Australia; Division of Psychiatry, School of Medicine, Perth, Australia
| | - Chee H Ng
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | - Yu-Ping Ning
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Yong-Dong Hu
- Department of Psychological Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | | | - Gang Wang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital & The Advanced Innovation Center for Human Brain Protection, Capital Medical University, School of Mental Health, Beijing, China.
| | - Yu-Tao Xiang
- Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida da Universidade, 3/F, Building E12 Taipa, Macao SAR, China..
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19
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S -ketamine compared to etomidate during electroconvulsive therapy in major depression. Eur Arch Psychiatry Clin Neurosci 2017; 267:803-813. [PMID: 28424861 DOI: 10.1007/s00406-017-0800-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 04/11/2017] [Indexed: 10/19/2022]
Abstract
Objective of the study was to compare two commonly used anesthetic drugs, S-ketamine and etomidate, regarding their influence on seizure characteristics, safety aspects, and outcome of electroconvulsive therapy (ECT) in major depression. Treatment data of 60 patients who underwent a total number of 13 ECTs (median) because of the severe or treatment-resistant major depressive disorder (DSM-IV) were analyzed. Etomidate, mean dosage (SD) = 0.25 (0.04) mg/kg, was used for anesthesia in 29 participants; 31 patients received S-ketamine, mean dosage (SD) = 0.96 (0.26) mg/kg. Right unilateral brief pulse ECTs were performed. The number of ECTs was individually adjusted to clinical needs, mean (SD) = 13.0 (4.3). Seizure characteristics, adverse events, and the clinical global impression (CGI) scores were compared between the both groups during ECT series. In the S-ketamine group, a lower initial seizure threshold (p = 0.014), stimulation charge (p < 0.001), higher postictal suppression (p < 0.001), EEG ictal amplitude (p = 0.04), EEG coherence (p < 0.001) and maximum heart rate (p = 0.015) were measured. Etomidate was associated with more frequent abortive seizures (p = 0.02) and restimulations (p = 0.01). The CGI scores, the number of sessions within an ECT series, and the incidence of adverse events did not differ between groups. Due to its lower initial seizure threshold, S-ketamine might hold a potential to become a clinically favorable anesthetic agent during ECT. However, the current findings should be interpreted with caution, and further prospective randomized clinical trials are required. Also, specific adverse effects profile of S-ketamine, especially with regard to the cardiovascular risk, needs to be taken into account.
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20
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Youssef NA, Sidhom E. Feasibility, safety, and preliminary efficacy of Low Amplitude Seizure Therapy (LAP-ST): A proof of concept clinical trial in man. J Affect Disord 2017; 222:1-6. [PMID: 28667887 DOI: 10.1016/j.jad.2017.06.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 05/07/2017] [Accepted: 06/12/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Current pulse amplitude used in clinical ECT may be higher than needed. Reducing pulse amplitude may improve focality of the electric field and thus cognitive adverse effects. Here we examine the feasibility, safety, and whether Low Pulse Amplitude Seizure Therapy (LAP-ST, 0.5-0.6A) minimizes cognitive adverse effects while retaining efficacy. METHODS Patients with treatment-resistant primary mood (depressive episodes) or psychotic disorders who were clinically indicated to undergo ECT were offered to be enrolled in an open-label study. The study consisted of a full acute course of LAP-ST under standard anesthesia and muscle relaxation. The primary outcome was feasibility of seizure induction. Clinical outcome measures were: time to reorientation (TRO), Mini Mental State Examination, Montgomery Aberg Depression Scale, and Brief Psychiatric Rating Scale, and Clinical Global Impression Scale. RESULTS Twenty-two patients consented for enrollment in the study. LAP-ST was feasible, and all patients had seizures in the first session. Participants had a quick orientation with median TRO of 4.5min. Treatment was efficacious for both depressive and psychotic symptoms. LIMITATIONS Relatively small sample size, non-blinded, and no randomization was performed in this initial proof of concept study. CONCLUSIONS This first human preliminary data of a full course of focal LAP-ST demonstrates that seizure induction is feasible. These results, although preliminary, suggest that the LAP-ST compared to the standard ECT techniques may result in less cognitive side effects, but comparable efficacy. Larger studies are needed to replicate these findings.
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Affiliation(s)
- Nagy A Youssef
- Department of Psychiatry and Health Behavior, Medical College of Georgia at Augusta University, 997 St. Sebastian Way, Augusta, GA 30912, USA.
| | - Emad Sidhom
- The Behman Hospital, Helwan, Cairo, Egypt; Oxford Health NHS Foundation Trust, UK
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21
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Gálvez V, McGuirk L, Loo CK. The use of ketamine in ECT anaesthesia: A systematic review and critical commentary on efficacy, cognitive, safety and seizure outcomes. World J Biol Psychiatry 2017; 18:424-444. [PMID: 27892759 DOI: 10.1080/15622975.2016.1252464] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES This review will discuss ECT efficacy and cognitive outcomes when using ketamine as an ECT anaesthetic compared to other anaesthetics, taking into account important moderator variables that have often not been considered to date. It will also include information on safety and other ECT outcomes (seizure threshold and quality). METHODS A systematic search through MEDLINE, PubMed, PsychINFO, Cochrane Databases and reference lists from retrieved articles was performed. Search terms were: "ketamine" and "Electroconvulsive Therapy", from 1995 to September 2016. Meta-analyses, randomised controlled trials, open-label and retrospective studies published in English of depressed samples receiving ECT with ketamine anaesthesia were included (n = 24). RESULTS Studies were heterogeneous in the clinical populations included and ECT treatment and anaesthetic methods. Frequently, studies did not report on ECT factors (i.e., pulse-width, treatment schedule). Findings regarding efficacy were mixed. Tolerance from repeated use may explain why several studies found that ketamine enhanced efficacy early in the ECT course but not at the end. The majority of studies did not comprehensively examine cognition and adverse effects were not systematically studied. Only a minority of the studies reported on seizure threshold and expression. CONCLUSIONS The routine use of ketamine anaesthesia for ECT in clinical settings cannot yet be recommended based on published data. Larger randomised controlled trials, taking into account moderator variables, specifically reporting on ECT parameters and systematically assessing outcomes are encouraged.
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Affiliation(s)
- Verònica Gálvez
- a School of Psychiatry, University of New South Wales (UNSW) , Sydney , NSW , Australia.,b Black Dog Institute , Sydney , NSW , Australia
| | - Lucy McGuirk
- a School of Psychiatry, University of New South Wales (UNSW) , Sydney , NSW , Australia.,b Black Dog Institute , Sydney , NSW , Australia
| | - Colleen K Loo
- a School of Psychiatry, University of New South Wales (UNSW) , Sydney , NSW , Australia.,b Black Dog Institute , Sydney , NSW , Australia.,c St. George Hospital , Sydney , Australia.,d Wesley Hospital , Sydney , Australia
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Franklin AD, Sobey JH, Stickles ET. Anesthetic considerations for pediatric electroconvulsive therapy. Paediatr Anaesth 2017; 27:471-479. [PMID: 28211248 DOI: 10.1111/pan.13115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2017] [Indexed: 01/23/2023]
Abstract
Electroconvulsive therapy is being used more frequently in the treatment of many chronic and acute psychiatric illnesses in children. The most common psychiatric indications for pediatric electroconvulsive therapy are refractory depression, bipolar disorder, schizophrenia, catatonia, and autism. In addition, a relatively new indication is the treatment of pediatric refractory status epilepticus. The anesthesiologist may be called upon to assist in the care of this challenging and vulnerable patient population. Unique factors for pediatric electroconvulsive therapy include the potential need for preoperative anxiolytic and inhalational induction of anesthesia, which must be weighed against the detrimental effects of anesthetic agents on the evoked seizure quality required for a successful treatment. Dexmedetomidine is likely the most appropriate preoperative anxiolytic as oral benzodiazepines are relatively contraindicated. Methohexital, though becoming less available at many institutions, remains the gold standard for induction of anesthesia for pediatric electroconvulsive therapy though ketamine, propofol, and sevoflurane are becoming increasingly viable options. Proper planning and communication between the multidisciplinary teams involved in the care of children presenting for electroconvulsive therapy treatments is vital to mitigating risks and achieving the greatest therapeutic benefit.
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Affiliation(s)
- Andrew D Franklin
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jenna H Sobey
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric T Stickles
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Lener MS, Kadriu B, Zarate CA. Ketamine and Beyond: Investigations into the Potential of Glutamatergic Agents to Treat Depression. Drugs 2017; 77:381-401. [PMID: 28194724 PMCID: PMC5342919 DOI: 10.1007/s40265-017-0702-8] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Clinical and preclinical studies suggest that dysfunction of the glutamatergic system is implicated in mood disorders such as major depressive disorder and bipolar depression. In clinical studies of individuals with major depressive disorder and bipolar depression, rapid reductions in depressive symptoms have been observed in response to subanesthetic-dose ketamine, an agent whose mechanism of action involves the modulation of glutamatergic signaling. The findings from these studies have prompted the repurposing and/or development of other glutamatergic modulators for antidepressant efficacy, both as monotherapy or as an adjunct to conventional monoaminergic antidepressants. This review highlights the evidence supporting the antidepressant effects of subanesthetic-dose ketamine as well as other glutamatergic modulators, such as D-cycloserine, riluzole, CP-101,606, CERC-301 (previously known as MK-0657), basimglurant, JNJ-40411813, dextromethorphan, nitrous oxide, GLYX-13, and esketamine.
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Affiliation(s)
- Marc S Lener
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, 10 Center Drive, Building 10/CRC, Room 7-5545, Bethesda, MD, USA.
| | - Bashkim Kadriu
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, 10 Center Drive, Building 10/CRC, Room 7-5545, Bethesda, MD, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, 10 Center Drive, Building 10/CRC, Room 7-5545, Bethesda, MD, USA
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Li DJ, Wang FC, Chu CS, Chen TY, Tang CH, Yang WC, Chow PCK, Wu CK, Tseng PT, Lin PY. Significant treatment effect of add-on ketamine anesthesia in electroconvulsive therapy in depressive patients: A meta-analysis. Eur Neuropsychopharmacol 2017; 27:29-41. [PMID: 27908572 DOI: 10.1016/j.euroneuro.2016.11.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 11/06/2016] [Accepted: 11/11/2016] [Indexed: 12/12/2022]
Abstract
Add-on ketamine anesthesia in electroconvulsive therapy (ECT) has been studied in depressive patients in several clinical trials with inconclusive findings. Two most recent meta-analyses reported insignificant findings with regards to the treatment effect of add-on ketamine anesthesia in ECT in depressive patients. The aim of this study is to update the current evidence and investigate the role of add-on ketamine anesthesia in ECT in depressive patients via a systematic review and meta-analysis. We performed a thorough literature search of the PubMed and ScienceDirect databases, and extracted all relevant clinical variables to compare the antidepressive outcomes between add-on ketamine anesthesia and other anesthetics in ECT. Total 16 articles with 346 patients receiving add-on ketamine anesthesia in ECT and 329 controls were recruited. We found that the antidepressive treatment effect of add-on ketamine anesthesia in ECT in depressive patients was significantly higher than that of other anesthetics (p<0.001). This significance persisted in both short-term (1-2 weeks) and moderate-term (3-4 weeks) treatment courses (all p<0.05). However, the side effect profiles and recovery time profiles were significantly worse in add-on ketamine anesthesia group than in control group. Our meta-analysis highlights the significantly higher antidepressive treatment effect of add-on ketamine in depressive patients receiving ECT compared to other anesthetics. However, clinicians need to take undesirable side effects into consideration when using add-on ketamine anesthesia in ECT in depressive patients.
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Affiliation(s)
- Dian-Jeng Li
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Taiwan; Department of Addiction Science, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
| | - Fu-Chiang Wang
- Department of Addiction Science, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
| | - Che-Sheng Chu
- Department of Psychiatry, Puli Branch, Taichung Veterans General Hospital, Taiwan
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Hung Tang
- Department of Psychiatry, Tainan Hospital, Ministry of Health and Welfare, Taiwan
| | - Wei-Cheng Yang
- Department of Adult Psychiatry, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
| | - Philip Chik-Keung Chow
- Department of Child and Adolescent Psychiatry, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
| | - Ching-Kuan Wu
- Department of Psychiatry, Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai׳s Home, Taiwan
| | - Ping-Tao Tseng
- Department of Psychiatry, Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai׳s Home, Taiwan.
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan; Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
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Kadiyala PK, Kadiyala LD. Anaesthesia for electroconvulsive therapy: An overview with an update on its role in potentiating electroconvulsive therapy. Indian J Anaesth 2017; 61:373-380. [PMID: 28584345 PMCID: PMC5444214 DOI: 10.4103/ija.ija_132_17] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Despite advances in pharmacotherapy, electroconvulsive therapy (ECT) remains a mainstay treatment option in psychiatry since its introduction in 1930s. It can be used primarily in severe illnesses when there is an urgent need for treatment or secondarily after failure or intolerance to pharmacotherapy. The 'unmodified' technique of ECT was practised initially, with a high incidence of musculoskeletal complications. Several modifications including general anaesthesia and muscle relaxation are used to increase the safety and patient acceptability of ECT. Various anaesthetic techniques including medications are considered to provide adequate therapeutic seizure, simultaneously controlling seizure-induced haemodynamic changes and side effects. A brief review of literature on choice of these anaesthetic techniques is discussed. This article is intended to reinforce the knowledge of clinicians, who may have limited exposure to ECT procedure. Importance is given to the recent updates on the role of induction agents in potentiating therapeutic response to ECT in psychiatric disorders.
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Affiliation(s)
- Pavan Kumar Kadiyala
- Department of Psychiatry, Siddhartha Medical College, Vijayawada, Andhra Pradesh, India
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