Seizures induced by low-dose right unilateral and bifrontal electroconvulsive stimuli

Noninvasive neuromodulation of the prefrontal cortex in mental health disorders

More than any other brain region, the prefrontal cortex (PFC) gives rise to the singularity of human experience. It is therefore frequently implicated in the most distinctly human of all disorders, those of mental health. Noninvasive neuromodulation, including electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS) among others, can-unlike pharmacotherapy-directly target the PFC and its neural circuits. Direct targeting enables significantly greater on-target therapeutic effects compared with off-target adverse effects. In contrast to invasive neuromodulation approaches, such as deep-brain stimulation (DBS), noninvasive neuromodulation can reversibly modulate neural activity from outside the scalp. This combination of direct targeting and reversibility enables noninvasive neuromodulation to iteratively change activity in the PFC and its neural circuits to reveal causal mechanisms of both disease processes and healthy function. When coupled with neuronavigation and neurophysiological readouts, noninvasive neuromodulation holds promise for personalizing PFC neuromodulation to relieve symptoms of mental health disorders by optimizing the function of the PFC and its neural circuits. ClinicalTrials.gov Identifier: NCT03191058.

Meta-analysis of initial seizure thresholds in electroconvulsive therapy

In electroconvulsive therapy (ECT), electrical dosage is determined using 'fixed-dose', 'age-based' dose, or empirical titration methods. Estimation of initial seizure threshold (IST) has been claimed to be imperative for suprathreshold dosing. This systematic review aimed to determine common levels of IST, to define cut-off values for high IST, and to summarize reported IST associated factors. Medline and PsycINFO were searched from 1966 to January 2008 and relevant references were cross-checked. Subject headings including ECT, seizure threshold, dosage, and dosing were used. All articles reporting on levels of IST and/or associated factors were included. Of 395 potentially relevant reports, 46 studies on 70 samples concerning 3,023 patients were selected. Nine samples (n = 306 patients) without available standard deviation and four samples (n = 275 patients) treated with mixed electrode placement were excluded. Meta-analysis was done on 30 unilaterally treated samples (n = 1,326 patients) and 27 bilaterally treated samples (n = 1,116 patients). In unilateral ECT, weighted mean of IST was 68.2 milliCoulombs (mC; 95% CI 63.2-73.3 mC), and in bilateral ECT 111.6 mC (95% CI 103.7-119.4 mC). Calculated cut-off values for high IST were 121 mC for unilateral ECT and 221 mC for bilateral ECT. According to the literature, male gender and use of bilateral electrode placement appeared to increase IST most prominently. In conclusion, calculated electrical doses for 'suprathreshold' right unilateral ECT and for 'moderate above threshold' bilateral ECT, using commonly reported IST levels, were in the same though narrower ranges as provided in 'fixed-dose' and 'half-age' based strategies, respectively.

Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: clinical efficacy

BACKGROUND

It has been suggested that electroconvulsive therapy (ECT) with an ultra-brief pulse width in combination with a bilateral electrode placement has diminished antidepressive efficacy, as compared to unilateral ultra-brief pulse ECT.

OBJECTIVE

The antidepressive efficacy of bifrontal and right unilateral ultra-brief pulse (0.3 ms) ECT were compared.

METHOD

Eighty-one patients with a medication refractory depressive episode were treated with a course of bifrontal ultra-brief pulse ECT at 1.5 times seizure threshold or unilateral ultra-brief pulse ECT at 6 times seizure threshold by random assignment. The 17 item-Hamilton Rating Scale for Depression (HRSD), Beck Depression Inventory, Clinical Global Impression and Patient Global Impression were administered at baseline and repeated weekly during and 1 and 6 weeks after the course, by a blinded rater.

RESULTS

64/81 patients (79%) completed the study, half of which were treated with bifrontal ECT. At the end of the course, 78.1% of the BF group and 78.1% of the UL group responded, whereas, 34.38% (N=11) of the BF group and 43.75% (N=14) of the UL group achieved strict remission criteria (HRSD-score < or = 7). There were no significant differences between the patients given bifrontal ECT and those given unilateral ECT, although patients receiving unilateral ECT achieved response/remission-criteria after a smaller number of treatments.

LIMITATIONS

Relatively small number of subjects.

CONCLUSIONS

Using an ultra-brief pulse width, both BF and UL-ECT are efficacious, although patients receiving UL-ECT achieve response/remission-criteria after a smaller number of treatments.

TRIAL REGISTRY

http://www.controlled-trials.com/

REGISTRATION NUMBER

ISRCTN56570426.

Comparison of clinical efficacy and side effects for bitemporal and bifrontal electrode placement in electroconvulsive therapy

OBJECTIVES

Bifrontal (BF) placement of electrodes in electroconvulsive therapy (ECT) has become a popular alternative to bitemporal (BT) placement. This study compares the clinical efficacy, side effects, and rehospitalization rates of BT and BF electrode placement in a community hospital setting.

METHODS

Charts from 76 patients receiving ECT treatments at Harborview Medical Center from 1994 to 2000 were reviewed to extract data on the characteristics of the course of ECT, clinical response, total headaches, narcotic and nonsteroidal anti-inflammatory drug doses, as well as documentation of confusion, disorientation, memory loss, and treatment emergent need for assistance with activities of daily living.

RESULTS

The BT patients experienced more clinical improvement during their stay (a 7-point greater change in Psychiatric Symptom Assessment Scale score, P < 0.05) and were significantly less likely to be rehospitalized within a 1-year time frame (odds ratio = 4.9, P = <0.05), even after controlling for relevant covariates. Although the two patient groups had equal rates of headache and analgesic administration, the BT placement caused significantly more cognitive impairment.

CONCLUSIONS

This study suggests that BT electrode placement offers better efficacy but modestly greater cognitive impairment than BF electrode placement.