Balancing speed of response to ECT in major depression and adverse cognitive effects: role of treatment schedule

Electroconvulsive shock increases neurotrophy and neurogenesis: Time course and treatment session effects

Increasing evidence suggests that hippocampal neurotrophy may be related to the development of major depressive disorders. Neurogenesis, which can be regulated by neurotrophic factors, is also involved in antidepressant efficacy. This paper reviewed literature on neurotrophic signaling and cell proliferation after electroconvulsive shock (ECS) treatment. All articles were from PubMed, Web of Science, and Scopus databases between 2000 and 2020. The keywords used in the literature search are: "ECS," "ECT," "electroconvulsive seizure," "electroconvulsive shock," "electroconvulsive therapy," "neurotrophic factor," "nerve growth factor," "neurotrophins," "neurogenesis," and "cell proliferation." Eighty-two articles were included in the final analysis. It was shown that compared with acute ECS, repeated ECS increased neurotrophin expression in more brain regions at higher levels and was maintained for a longer time. Similarly, ECS increased cell proliferation in a dose- and time-dependent manner. The increase in cell proliferation was positively correlated with the amount of ECS administered and the newly born cells survived for a long time. The effects of ECS in inducing increases in neurotrophin levels and neurogenesis may contribute to brain function changes and antidepressant effects. Future research may focus on optimal sessions of ECT treatment to obtain the best therapeutic effect.

Case report: delayed response after electroconvulsive therapy in a patient with major depressive disorder

BACKGROUND

Major depressive disorder and associated mood syndromes are amongst the most common psychiatric disorders. To date, electroconvulsive therapy (ECT) is considered the most effective short-term treatment for patients with severe or treatment-resistant depression. In clinical practice, there is considerable variation in the ECT dosing schedule, with the number of sessions typically ranging from 6 to 12, with early antidepressant effects being predictive of increased positive outcomes. We describe here an unusual case of a female patient with severe depression who did not respond to ECT until the 11th session, after which she had shown a drastic improvement in her mental state.

CASE PRESENTATION

A 75-year-old female presented to the old age psychiatry inpatient unit with new onset dysphoric mood, anhedonia, and severe negativity. She scored 23 on the 17-item Hamilton Rating Scale for Depression (HAM-D), and was rated 6 on Clinical Global Impression severity (CGIS) by the responsible clinician. She suffered from post-natal depression fifty years ago and was successfully treated with ECT. She was therefore initiated on a course of ECT treatment. Her condition initially deteriorated, displaying features of catatonia and psychosis, unresponsive to ECT treatment or concurrent psychotropic medications. After 11th ECT session, she started to show signs of clinical improvement and returned close to her baseline mental state after a total of 17 ECT sessions. She remained well 3 months post-treatment, scoring 4 on HAM-D, Clinical Global Improvement or change (CGI-C) rated as 1 (very much improved). The diagnosis was ICD-10 F32.3 severe depressive episode with psychotic symptoms.

CONCLUSIONS

we describe here an unusual case of delayed response to electroconvulsive therapy in the treatment of severe depressive disorder. Studies have shown the number of acute ECT treatments to be highly variable, affected by a number of factors including treatment frequency, condition treated and its severity, the ECT technical parameters, as well as concurrent use of pharmacological treatment. This may call for re-consideration of the current ECT treatment guidelines, requiring more research to help stratify and standardize the treatment regime.

Maintenance ECT is associated with sustained improvement in depression symptoms without adverse cognitive effects in a retrospective cohort of 100 patients each receiving 50 or more ECT treatments

BACKGROUND

Electroconvulsive therapy (ECT) is the most effective acute treatment for depression, but relapse is common following discontinuation. One strategy for prolonging remission is the use of maintenance ECT, but the clinical evidence supporting its efficacy and safety are limited. We examined the effects of maintenance ECT on depression and cognition.

METHODS

Participants were from a retrospective cohort of 100 patients receiving ECT at a freestanding psychiatric hospital and who received at least 50 treatments during a single treatment series. QIDS, BASIS-24, and MoCA were assessed at baseline and every 10 treatments thereafter during the clinical course.

RESULTS

ECT was associated with a rapid decrease in depression symptoms and overall self-reported mental health status within the first 10 treatments, which was sustained throughout a median of 22.1 months of follow-up. There was no change in cognitive functioning as measured by the MoCA. Bilateral and brief pulse treatment parameters were more common by treatment 50 than at the first treatment. Most participants either continued in ECT at the end of the study period or discontinued due to sustained remission.

LIMITATIONS

retrospective observational study without control group who did not receive ECT.

CONCLUSIONS

In this ECT cohort with at least 50 treatments, improvement in depression was sustained on QIDS and BASIS-24 and adverse cognitive effects were not detected by serial MoCAs, supporting the utility of maintenance ECT in this cohort.

Frequency and Duration of Course of ECT Sessions: An Appraisal of Recent Evidence

AIMS AND METHOD

This paper aims to review the recent literature regarding factors influencing the frequency and number of sessions during a course of electroconvulsive therapy (ECT) for different psychiatric disorders. We systematically reviewed English-language papers of clinical trials of ECT published since the year 2000 in terms of frequency and number of sessions of ECT.

RESULTS

None of the 30 studies meeting our inclusion criteria were specifically designed to study frequency or number of sessions of ECT. A preliminary inference may be drawn regarding the number of sessions from the information available in these papers. For depression, patients receiving brief-pulse ECT needed fewer sessions than those receiving ultra-brief ECT when these were delivered at 8-times the threshold with unilateral electrode placement or at 2.5-times the threshold with bilateral placement. For schizophrenia, those receiving bifrontal ECT and ECT at 4-times the threshold-level stimulus needed fewer sessions than those receiving bitemporal ECT and 2-times the threshold-level stimulus, respectively. There were no clinical trials of the frequency of ECT sessions.

CLINICAL IMPLICATIONS

As there is a dearth of studies specifically examining frequency and number of ECT sessions, broad recommendations from professional bodies should continue to guide practice.

Correlates of self-reported, autobiographical, and mini-mental status examination defined memory deficits following electroconvulsive therapy in South India

BACKGROUND

Cognitive deficits, self-reported or found following electroconvulsive therapy (ECT), and their correlates are diverse. Despite the characteristics of people receiving ECT in Asia differ widely from the west, pertinent research from Asia remains sparse.

METHODS

We investigated the correlates of self-reported, mini-mental status examination (MMSE) defined, and autobiographical memory deficits in a cohort that received ECT in a south Indian tertiary-care setting. 76 consecutive consenting people were recruited within seven days of completing their ECT course. Memory was assessed by a subjective Likert scale, MMSE, and an autobiographical memory scale (AMS). Psychopathology was assessed by brief psychiatric rating scale, and serum cortisol levels were estimated by chemi-luminescence immunoassays. Relevant sociodemographic and clinical data were collected from the participants, and their medical records. The correlates were analysed using generalised linear models after adjusting for the effects of potential confounders.

RESULTS

Self-reported, MMSE-defined, and autobiographical memory deficits were present in 27.6% (95%CI 17.6-37.7%), 42.1% (95%CI 31.0-53.2%), and 36.8% (95%CI 26.0-47.7%) of participants, respectively. Agreement between the memory deficits was poor. Age, less education, duration of illness, hypothyroidism, and past history of another ECT course were significantly associated with MMSE-defined deficits. Age, anaemia, past ECT course, and pre-ECT blood pressure were significantly associated with autobiographical memory deficits, while residual psychopathology and cortisol levels were significantly associated with self-reported memory deficits.

CONCLUSION

Self-reported, MMSE-defined, and autobiographical memory deficits are common at the completion of ECT course, and their correlates differ. All service users receiving ECT need periodic cognitive assessments evaluating multiple cognitive domains.

Electroconvulsive therapy regulates emotional memory bias of depressed patients

Emotional memory bias is considered to be an important base of the etiology of depression and can be reversed by antidepressants via enhancing the memory for positive stimuli. Another antidepressant treatment, electroconvulsive therapy (ECT), has rapid antidepressant effect and frequently causes short-term memory impairment. However, it is unclear about the short-term effect of ECT on memory bias. In this study, the incidental memory task with emotional pictures were applied to evaluate the emotional memory of twenty depressed patients at pre- and post-ECT (three days after ECT) compared to twenty healthy controls. The depressive symptoms were evaluated using the Hamilton rating scale of depression (HRSD). Before ECT, patients showed decreased recognition memory for positive pictures compared to controls and remembered negative pictures more easily than positive pictures in the recognition task. In patients, the main effect of session (pre-ECT and post-ECT) was significant for both recognition and recall memory with reduced memory performance. The interaction between valence (positive, neutral and negative) and session was significant for recognition memory, indicating that negative memory was impaired more severely than positive memory. Our study indicates that ECT relieves depressive symptoms and regulates emotional memory through more severe impairment on memory for negative stimuli.

Mouse repeated electroconvulsive seizure (ECS) does not reverse social stress effects but does induce behavioral and hippocampal changes relevant to electroconvulsive therapy (ECT) side-effects in the treatment of depression

Electroconvulsive therapy (ECT) is an effective treatment for depression, but can have negative side effects including amnesia. The mechanisms of action underlying both the antidepressant and side effects of ECT are not well understood. An equivalent manipulation that is conducted in experimental animals is electroconvulsive seizure (ECS). Rodent studies have provided valuable insights into potential mechanisms underlying the antidepressant and side effects of ECT. However, relatively few studies have investigated the effects of ECS in animal models with a depression-relevant manipulation such as chronic stress. In the present study, mice were first exposed to chronic social stress (CSS) or a control procedure for 15 days followed by ECS or a sham procedure for 10 days. Behavioral effects were investigated using an auditory fear conditioning (learning) and expression (memory) test and a treadmill-running fatigue test. Thereafter, immunohistochemistry was conducted on brain material using the microglial marker Iba-1 and the cholinergic fibre marker ChAT. CSS did not increase fear learning and memory in the present experimental design; in both the control and CSS mice ECS reduced fear learning and fear memory expression. CSS induced the expected fatigue-like effect in the treadmill-running test; ECS induced increased fatigue in CSS and control mice. In CSS and control mice ECS induced inflammation in hippocampus in terms of increased expression of Iba-1 in radiatum of CA1 and CA3. CSS and ECS both reduced acetylcholine function in hippocampus as indicated by decreased expression of ChAT in several hippocampal sub-regions. Therefore, CSS increased fatigue and reduced hippocampal ChAT activity and, rather than reversing these effects, a repeated ECS regimen resulted in impaired fear learning-memory, increased fatigue, increased hippocampal Iba-1 expression, and decreased hippocampal ChAT expression. As such, the current model does not provide insights into the mechanism of ECT antidepressant function but does provide evidence for pathophysiological mechanisms that might contribute to important ECT side-effects.

The use of ketamine in ECT anaesthesia: A systematic review and critical commentary on efficacy, cognitive, safety and seizure outcomes

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.

The Role of Electroconvulsive Therapy (ECT) in Bipolar Disorder: Effectiveness in 522 Patients with Bipolar Depression, Mixed-state, Mania and Catatonic Features

OBJECTIVE

We evaluated the effectiveness of Electroconvulsive Therapy (ECT) in the treatment of Bipolar Disorder (BD) in a large sample of bipolar patients with drug resistant depression, mania, mixed state and catatonic features.

METHOD

522 consecutive patients with DSM-IV-TR BD were evaluated prior to and after the ECT course. Responders and nonresponders were compared in subsamples of depressed and mixed patients. Descriptive analyses were reported for patients with mania and with catatonic features.

RESULTS

Of the original sample only 22 patients were excluded for the occurrence of side effects or consent withdrawal. After the ECT course, 344 (68.8%) patients were considered responders (final CGIi score ≤2) and 156 (31.2%) nonresponders. Response rates were respectively 68.1% for BD depression, 72.9% for mixed state, 75% for mania and 80.8% for catatonic features. Length of current episode and global severity of the illness were the only statistically significant predictors of nonresponse.

CONCLUSION

ECT resulted to be an effective and safe treatment for all the phases of severe and drug-resistant BD. Positive response was observed in approximately two-thirds of the cases and in 80% of the catatonic patients. The duration of the current episode was the major predictor of nonresponse. The risk of ECT-induced mania is virtually absent and mood destabilization very unlikely. Our results clearly indicate that current algorithms for the treatment of depressive, mixed, manic and catatonic states should be modified and, at least for the most severe patients, ECT should not be considered as a "last resort".

Early Complete Remitters After Electroconvulsive Therapy: Profile and Prognosis

OBJECTIVE

To investigate the prevalence, characteristics, and prognosis of depressive patients who show early complete remission after right unilateral (ultra)brief pulse electroconvulsive therapy (ECT).

METHODS

Early complete remitters (ECRs) were those patients who were rated 1 on the Clinical Global Impression Scale (maximum score, 7) within 4 ECT sessions and achieved remission (Montgomery Åsberg Depression Rating Scale score, <10). The ECRs were compared with late complete remitters (LCRs), which fulfilled the same criteria after 9 to 12 ECT sessions and with the nonremitters/nonresponders (NRs).

RESULTS

Of the 87 patients who completed the index treatment phase, 50 (57.5%) achieved remission. Of these remitters, 12 (14%) were ECRs and 9 (10%) were LCRs. The ECRs were characterized by a higher mean age (71.0 vs 53.9 years; P = 0.008), a shorter current depressive episode (mean, 5.8 vs 15.4 months; P = 0.042), and more psychotic features (75% vs 22%; P = 0.030) and were treated more often with brief pulse ECT (P = 0.030) compared with the LCRs. Although not significant, cognitive performances of ECRs were lower than that of LCRs at baseline with a large effect size: Autobiographical Memory Interview (P = 0.099; d = 0.83), Amsterdam Media Questionnaire (P = 0.114; d = 0.84), and Letter fluency (P = 0.071; d = 0.95). The ECR group had a lower relapse rate during 6 months' follow-up: 10% (1 of 10) versus 62.5% (5 of 8) (P = 0.043). No significant differences in demographic and clinical characteristics were found between LCRs (n = 9) and NRs (n = 27).

CONCLUSIONS

Older patients with a psychotic depression and a profile of cognitive slowing have a high chance of achieving complete remission within 4 ECT sessions, with a favorable 6-month prognosis.

The acute and medium-term effects of treatment with electroconvulsive therapy on memory in patients with major depressive disorder

BACKGROUND

Current literature provides insufficient information on the degree of cognitive impairment during and after electroconvulsive therapy (ECT), mostly due to the fact that applied tests lacked sensitivity and flexibility. Our goal was to evaluate cognitive functioning in adult depressed patients treated with bi-temporal ECT, using tests sensitive for detection of possible acute and medium-term memory changes.

METHOD

Thirty adult patients with major depressive disorder, treated with a course of bi-temporal ECT, underwent clinical and cognitive measurements three times: at baseline, immediately after a course of ECT, and 1 month later. For cognition assessment, we used learning and visual, spatial and figural memory tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB).

RESULTS

Bi-temporal ECT has proven to be an effective treatment. The linear mixed model, used to analyze changes in depression severity and patients' cognitive performances over time and to assess dynamic correlations between aforementioned features, did not show any significant memory impairment as a potential acute or medium-term ECT effect. However, it yielded significant improvement on visual memory and learning at the follow-up, which positively correlated with the improvement of depression.

CONCLUSION

Good progress is being made in the search for ECT-related acute and medium-term cognitive side-effects by using the tests sensitive to detect memory dysfunction with parallel forms of the tasks (to counter practice effects on repeat testing). Our results on learning and memory in relation to ECT during treatment of depression did not bring forth any prolonged and significant bi-temporal ECT-related memory deficit.

Pharmacological management of unipolar depression

OBJECTIVE

To be used in conjunction with 'Psychological management of unipolar depression' [Lampe et al. Acta Psychiatr Scand 2013;127(Suppl. 443):24-37] and 'Lifestyle management of unipolar depression' [Berk et al. Acta Psychiatr Scand 2013;127(Suppl. 443):38-54]. To provide clinically relevant recommendations for the use of pharmacological treatments in depression derived from a literature review.

METHOD

Using our previous Clinical Practice Guidelines [Malhi et al. Clinical practice recommendations for bipolar disorder. Acta Psychiatr Scand 2009;119(Suppl. 439):27-46] as a foundation, these clinician guidelines target key practical considerations when prescribing pharmacotherapy. A comprehensive review of the literature was conducted using electronic database searches (PubMed, MEDLINE), and the findings have been synthesized and integrated alongside clinical experience.

RESULTS

The pharmacotherapy of depression is an iterative process that often results in partial and non-response. Beyond the initiation of antidepressants, the options within widely used strategies, such as combining agents and switching between agents, are difficult to prescribe because of the paucity of pertinent research. However, there is some evidence for second-line strategies, and a non-prescriptive algorithm can be derived that is based broadly on principles rather than specific steps.

CONCLUSION

Depression is by its very nature a heterogeneous illness that is consequently difficult to treat. Invariably, situation-specific factors often play a significant role and must be considered, especially in the case of partial and non-response. Consulting with colleagues and trialling alternate treatment paradigms are essential strategies in the management of depression.

Electroconvulsive therapy for catatonia: treatment characteristics and outcomes in 27 patients

OBJECTIVES

Electroconvulsive therapy (ECT) has been described as an effective treatment option for catatonia in retrospective case series. We aimed to investigate treatment characteristics and outcomes of patients with catatonia who were treated with ECT.

METHODS

The medical records of 27 patients with catatonia treated with ECT (between 1991 and 2009) were scrutinized for clinical and treatment characteristics. Outcomes were measured using the Clinical Global Impression-Improvement (CGI-I) scale. Patients who improved (defined as CGI-I score "very much" or "much improved") were compared with those who did not improve (defined as a CGI-I score "no change" or "very much worse").

RESULTS

Mean age of all patients was 49 ± 19 years, of whom 15 (56%) were women. Of all patients, 13 (48%) had a diagnosis of a mood disorder and 12 (44%) of a psychotic disorder. Electroconvulsive therapy was mostly started after ineffective pharmacotherapy (n=23; 85%) within 2 to 3 months after catatonia had been diagnosed. In total, 16 (59%) patients improved. Improvement was significantly associated with younger age (P=0.05), presence of autonomic dysregulation at baseline (P=0.02), especially higher body temperature (P=0.02), daily ECT during the first treatment week (n=15 [56%]; P=0.03), longer duration of electroencephalogram seizure activity at last ECT session (P=0.04), and less morbidity in the year after ECT (P=0.03). Three of 11 nonimproved patients died in the year after ECT compared with none of the improved patients.

CONCLUSIONS

Most of our patients with catatonia benefited from ECT, especially younger patients with autonomic dysregulation. Daily administration of ECT may be more effective, whereas longer duration of seizure activity at the final ECT session was related to better response to ECT.

Therapeutic options for treatment-resistant depression

Treatment-resistant depression (TRD) presents major challenges for both patients and clinicians. There is no universally accepted definition of TRD, but results from the US National Institute of Mental Health's (NIMH) STAR*D (Sequenced Treatment Alternatives to Relieve Depression) programme indicate that after the failure of two treatment trials, the chances of remission decrease significantly. Several pharmacological and nonpharmacological treatments for TRD may be considered when optimized (adequate dose and duration) therapy has not produced a successful outcome and a patient is classified as resistant to treatment. Nonpharmacological strategies include psychotherapy (often in conjunction with pharmacotherapy), electroconvulsive therapy and vagus nerve stimulation. The US FDA recently approved vagus nerve stimulation as adjunctive therapy (after four prior treatment failures); however, its benefits are seen only after prolonged (up to 1 year) use. Other nonpharmacological options, such as repetitive transcranial stimulation, deep brain stimulation or psychosurgery, remain experimental and are not widely available. Pharmacological treatments of TRD can be grouped in two main categories: 'switching' or 'combining'. In the first, treatment is switched within and between classes of compounds. The benefits of switching include avoidance of polypharmacy, a narrower range of treatment-emergent adverse events and lower costs. An inherent disadvantage of any switching strategy is that partial treatment responses resulting from the initial treatment might be lost by its discontinuation in favour of another medication trial. Monotherapy switches have also been shown to have limited effectiveness in achieving remission. The advantage of combination strategies is the potential to build upon achieved improvements; they are generally recommended if partial response was achieved with the current treatment trial. Various non-antidepressant augmenting agents, such as lithium and thyroid hormones, are well studied, although not commonly used. There is also evidence of efficacy and increasing use of atypical antipsychotics in combination with antidepressants, for example, olanzapine in combination with fluoxetine (OFC) or augmentation with aripiprazole. The disadvantages of a combination strategy include multiple medications, a broader range of treatment-emergent adverse events and higher costs. Several experimental pharmaceutical treatment alternatives for TRD are also being explored in combination with antidepressants or as monotherapy. These less studied alternative compounds include pindolol, inositol, CNS stimulants, hormones, herbal supplements, omega-3 fatty acids, S-adenosyl-L-methionine, folic acid, lamotrigine, modafinil, riluzole and topiramate. In summary, despite an increasing variety of choices for the treatment of TRD, this condition remains universally undefined and represents an area of unmet medical need. There are few known approved pharmacological agents for TRD (aripiprazole and OFC) and overall outcomes remain poor. This might be an indication that depression itself is a heterogeneous condition with a great diversity of pathologies, highlighting the need for careful evaluation of individuals with depressive symptoms who are unresponsive to treatment. Clearly, more research is needed to provide clinicians with better guidance in making those treatment decisions--especially in light of accumulating evidence that the longer patients are unsuccessfully treated, the worse their long-term prognosis tends to be.

Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. IV. Neurostimulation therapies

BACKGROUND

In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. There is renewed interest in refined approaches to brain stimulation, particularly for treatment resistant major depressive disorder (MDD).

METHODS

The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support. This section on "Neurostimulation Therapies" is one of 5 guidelines articles.

RESULTS

Among the four forms of neurostimulation reviewed in this section, electroconvulsive therapy (ECT) has the most extensive evidence, spanning seven decades. Repetitive transcranial magnetic (rTMS) and vagus nerve stimulation (VNS) have been approved to treat depressed adults in both Canada and the United States with a much smaller evidence base. There is also emerging evidence that deep brain stimulation (DBS) is effective for otherwise treatment resistant depression, but this is an investigational approach in 2009.

LIMITATIONS

Compared to other modalities for the treatment of MDD, the data based is limited by the relatively small numbers of randomized controlled trials (RCTs) and small sample sizes.

CONCLUSIONS

There is most evidence to support ECT as a first-line treatment under specific circumstances and rTMS as a second-line treatment. Evidence to support VNS is less robust and DBS remains an investigational treatment.

Cognitive side effects of brief pulse electroconvulsive therapy: a review

Cognitive impairment remains a common side effect of brief pulse electroconvulsive therapy (ECT), and its minimization has been the motivation for many different treatment modifications over the decades. The level of impairment has been shown to vary according to different technical parameters of ECT including, but not limited to, electrode placement, dosage, and waveform, as well as patient factors, such as age and premorbid intellect. Most past research has focused the assessment on memory impairments associated with ECT. Specifically, ECT can result in both anterograde and retrograde memory impairments. However, the study of non-memory cognitive functions after ECT has been relatively neglected. Furthermore, although considerable recovery has been observed within weeks of treatment completion, data are lacking in the longer term. The following article presents an overview of what is currently known about the pattern and recovery of cognitive side effects of ECT. Controversies within the literature and areas requiring further research are highlighted.

Memory performance in severely depressed patients treated by electroconvulsive therapy

OBJECTIVES

Depression is accompanied by disturbed implicit (unconscious) and explicit (conscious) memory functions. The aim was the assessment of immediate and delayed verbal and visual memory functions, concentration/attention during the course of electroconvulsive therapy (ECT) treatment.

METHODS

Twenty severely depressed, drug-treatment resistant, elderly patients were assessed with the Wechsler Memory Scale-Revised (WMS-R) before and at the end of the ECT series.

RESULTS

Patients revealed deficits in acquisition (immediate verbal and visual memory), attention/concentration, and retrieval of information (delayed memory) before ECT. After ECT, significant improvements were observed in immediate memory but not in delayed memory. Although higher total stimulation levels (millicoulombs) (P = 0.015) were associated with improvements in immediate visual memory, we found that longer duration of convulsions (P = 0.016) as well as lower levels of stimulation at last ECT (P = 0.036) were associated with improvements in immediate verbal memory. Moreover, we found that stimulation energy (millicoulombs) in total and at last ECT was the best predictor among several clinical and ECT parameters of improved visual memory and concentration and decreased verbal and general memory.

CONCLUSIONS

Prefrontal cortex-related memory processes, especially immediate memory encoding, improved after ECT, whereas long-term memory remained impaired, indicating that severely depressed patients remain cognitively inferior to normal subjects despite clinically successful treatment. This study may yield a better understanding of the time course of memory alterations in severely depressed patients receiving ECT. Improvement of immediate memory may be essential for establishing normal daily activities of life in the recovery phase of depression.

Evidências da eficácia da eletroconvulsoterapia na prática psiquiátrica

A eletroconvulsoterapia (ECT) consiste em tratamento biológico ainda não amplamente utilizado na prática psiquiátrica, devido aos inúmeros fatores que contribuem para uma resistência acerca do método. Objetivando sustentar, com embasamento científico, o emprego da ECT, agregamos evidências de sua eficácia, indicações, contra-indicações e efeitos adversos, advindas dos principais ensaios clínicos randomizados e meta-análises disponíveis na literatura médica atual sobre o tema (PubMed/MEDLINE, Cochrane).

Effect of stimulus intensity and number of treatments on ECS-related seizure duration and retrograde amnesia in rats

BACKGROUND

Animal models are frequently used to generate and test hypotheses about amnesia resulting from electroconvulsive therapy (ECT). Although many predictors of ECT-induced amnesia are known, their relative effects have been inadequately researched in the context of the animal models.

OBJECTIVE

We sought to determine the relative retrograde amnestic effects of electroconvulsive shock (ECS) stimulus intensity (dose) and number on strong memories in rats. We also sought to identify dose-dependent ceiling amnestic effects, if any.

METHODS

Adult rats (n = 144) were overtrained in a passive avoidance task using a step down apparatus. The rats were then randomized in a factorial design to receive one, two, or three once-daily bilateral ECS at 0-mC (sham ECS), 30-mC, 60-mC, 120-mC, or 180-mC doses. Recall of the pre-ECS training was assessed 1 day after the last ECS.

RESULTS

Retrograde amnesia was observed only in rats that received 3 ECS; dose-dependent amnestic effects did not emerge. Higher stimulus intensity was associated with a small (13%) but significant increase in motor seizure duration, but only at the first ECS; stimulus intensity did not influence the attenuation of seizure duration across repeated occasions of ECS.

CONCLUSION

With bilateral ECS, the number of ECSs administered is a more important variable than the ECS dose in weakening a strong, recently acquired, noxious memory; this finding may have important clinical implications. Higher stimulus intensity marginally increases motor seizure duration at the first ECS but does not influence the decrease in seizure duration across repeated ECSs.

Effective use of electroconvulsive therapy in late-life depression

OBJECTIVE

To review literature pertaining to the efficacy, safety, and tolerability of electroconvulsive therapy (ECT) in treating late-life depression.

METHOD

We undertook a literature review with an emphasis on research studies published in the last 10 years.

RESULTS

There is a positive association between advancing age and ECT efficacy. Age per se does not necessarily increase the risk of cognitive side effects from ECT, but this risk is increased by age-associated neurological conditions such as Alzheimer's dementia and cerebrovascular disease. With appropriate evaluation and monitoring, ECT can be used safely in patients of very advanced age and in those with serious medical conditions. Several technical factors, including dose of electricity relative to a patient's seizure threshold, position of electrodes, frequency of administration, and total number of treatments, have an impact on the efficacy and cognitive side effects of ECT and need to be taken into account when administering ECT. Naturalistic studies have found that 50% of more of patients have a relapse of depression within 6 to 12 months of discontinuing acute ECT.

CONCLUSIONS

In recent years, there has been substantial progress in our understanding of the effect of technical factors on the efficacy and cognitive side effects of ECT. When administered in an optimal manner, ECT is a safe, well-tolerated, and effective treatment in older patients. Relapse of depression after response to ECT remains a significant problem, and there is a need for further research into the prediction and prevention of post-ECT relapse.

Effect of piracetam on ECT-induced cognitive disturbances: a randomized, placebo-controlled, double-blind study

Electroconvulsive therapy (ECT) is still the fastest, most effective, and frequently life-saving therapeutic intervention in several forms of depression and some other psychiatric disorders. Transient memory disturbances are frequent after ECT. A randomized, double-blind, placebo-controlled study was conducted to investigate the effects of piracetam on ECT-induced confusion and memory disturbances. Thirty-eight consecutively admitted patients with depressive illness or schizophrenia requiring ECT were given either piracetam or an identical-looking placebo during the period of ECT treatment and for 2 weeks afterward. Daily dosage of piracetam was 7.2 g, given orally for the first 2 weeks while patients underwent ECT (loading phase), followed by 4.8 g for the rest of the study period. Participants were evaluated by standardized clinical rating scales and cognitive psychologic tests 1 to 2 days before ECT, 1 day after their third and sixth ECT treatments, and 2 weeks after they had completed their ECT courses. Piracetam had no significant effect in preventing ECT-induced memory disturbances. All clinical ratings were consistently, albeit not significantly, better in the piracetam group, suggesting that piracetam may have augmented the effects of ECT.