1
|
Elias A, Thomas N, Sackeim HA. Electroconvulsive Therapy in Mania: A Review of 80 Years of Clinical Experience. Am J Psychiatry 2021; 178:229-239. [PMID: 33167675 DOI: 10.1176/appi.ajp.2020.20030238] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Resistance to pharmacological agents is commonly encountered in the treatment of acute episodes of mania. In contemporary practice guidelines, electroconvulsive therapy (ECT), once a widely used standalone intervention for mania, is no longer considered a first-line treatment. Stigma, logistics, and ethical factors constrain ECT administration in this condition and lead to its underutilization. However, the past three decades have produced promising research regarding the use of ECT in mania. Randomized controlled trials, albeit in limited numbers, the adoption of ultrabrief ECT, examination of the safety and efficacy of combining ECT with pharmacological agents, including lithium, and use of ECT as a maintenance strategy have enhanced our understanding of how and when to utilize this intervention in mania. In this comprehensive review, the authors summarize the evidence regarding the efficacy and safety of ECT in mania, including related syndromes, such as delirious mania and mixed affective states. The impact of technical parameters, particularly the choice of treatment frequency, electrode placements, and pulse width, are discussed in the light of recent evidence.
Collapse
Affiliation(s)
- Alby Elias
- Department of Psychiatry, University of Melbourne, Victoria, Australia (Elias, Thomas); Departments of Psychiatry and Radiology, College of Physicians and Surgeons, Columbia University, New York (Sackeim)
| | - Naveen Thomas
- Department of Psychiatry, University of Melbourne, Victoria, Australia (Elias, Thomas); Departments of Psychiatry and Radiology, College of Physicians and Surgeons, Columbia University, New York (Sackeim)
| | - Harold A Sackeim
- Department of Psychiatry, University of Melbourne, Victoria, Australia (Elias, Thomas); Departments of Psychiatry and Radiology, College of Physicians and Surgeons, Columbia University, New York (Sackeim)
| |
Collapse
|
2
|
Malhi GS, Bell E, Bassett D, Boyce P, Bryant R, Hazell P, Hopwood M, Lyndon B, Mulder R, Porter R, Singh AB, Murray G. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry 2021; 55:7-117. [PMID: 33353391 DOI: 10.1177/0004867420979353] [Citation(s) in RCA: 244] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility. METHODS Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders. RESULTS The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg2020) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care. CONCLUSION The MDcpg2020 builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus. MOOD DISORDERS COMMITTEE Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.
Collapse
Affiliation(s)
- Gin S Malhi
- The University of Sydney, Faculty of Medicine and Health, Northern Clinical School, Department of Psychiatry, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Erica Bell
- The University of Sydney, Faculty of Medicine and Health, Northern Clinical School, Department of Psychiatry, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | | | - Philip Boyce
- Department of Psychiatry, Westmead Hospital and the Westmead Clinical School, Wentworthville, NSW, Australia.,Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Philip Hazell
- Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne and Professorial Psychiatry Unit, Albert Road Clinic, Melbourne, VIC, Australia
| | - Bill Lyndon
- The University of Sydney, Faculty of Medicine and Health, Northern Clinical School, Department of Psychiatry, Sydney, NSW, Australia
| | - Roger Mulder
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Porter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Ajeet B Singh
- The Geelong Clinic Healthscope, IMPACT - Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Greg Murray
- Centre for Mental Health, Swinburne University of Technology, Hawthorn, VIC, Australia
| |
Collapse
|
3
|
Abbott CC, Miller J, Lloyd M, Tohen M. Electroconvulsive therapy electrode placement for bipolar state-related targeted engagement. Int J Bipolar Disord 2019; 7:11. [PMID: 31053985 PMCID: PMC6499851 DOI: 10.1186/s40345-019-0146-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/19/2019] [Indexed: 02/06/2023] Open
Abstract
Background Electroconvulsive therapy (ECT) is an effective treatment for all bipolar states. However, ECT remains underutilized, likely stemming from stigma and the risk of neurocognitive impairment. Neuroimaging research has identified state-specific areas of aberrant brain activity that may serve as targets for therapeutic brain stimulation. Electrode placement determines the geometry of the electric field and can be either non-focal (bitemporal) or more focal (right unilateral or bifrontal). Previous research has shown that electrode placement can impact clinical and cognitive outcomes independent of seizure activity. This review critically examines the evidence that focal (unilateral or bifrontal) electrode placements target specific aberrant circuitry in specific bipolar states to optimize clinical outcomes. We hypothesize that optimal target engagement for a bipolar state will be associated with equivalent efficacy relative to bitemporal non-focal stimulation with less neurocognitive impairment. Methods We performed a literature search in the PubMed database. Inclusion criteria included prospective, longitudinal investigations during the ECT series with specific electrode placements within a bipolar state from 2000 to 2018. Results We identified investigations that met our inclusion criteria with bipolar mania (n = 6), depression (n = 6), mixed (n = 3) and catatonia (n = 1) states. These studies included clinical outcomes and several included cognitive outcomes, which were discussed separately. Conclusions While the heterogeneity of the studies makes comparisons difficult, important patterns included the reduced cognitive side effects, faster rate of response, and equivalent efficacy rates of the focal electrode placements (right unilateral and bifrontal) when compared to non-focal (bitemporal) placement. Further avenues for research include more robust cognitive assessments to separate procedure-related and state-related impairment. In addition, future studies could investigate novel electrode configurations with more specific target engagement for different bipolar states.
Collapse
Affiliation(s)
- Christopher C Abbott
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, University of New Mexico School of Medicine, Albuquerque, NM, 87131, USA.
| | - Jeremy Miller
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, University of New Mexico School of Medicine, Albuquerque, NM, 87131, USA
| | - Megan Lloyd
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, University of New Mexico School of Medicine, Albuquerque, NM, 87131, USA
| | - Mauricio Tohen
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, University of New Mexico School of Medicine, Albuquerque, NM, 87131, USA
| |
Collapse
|
4
|
Effectiveness and Cognitive Changes With Ultrabrief Right Unilateral and Other Forms of Electroconvulsive Therapy in the Treatment of Mania. J ECT 2019; 35:40-43. [PMID: 29952862 DOI: 10.1097/yct.0000000000000519] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) is an effective treatment in mania. However, there is little evidence regarding the use of ultrabrief right unilateral (RUL-UB) ECT in treatment of acute manic episodes. The aim of this study was to report on the effectiveness and cognitive profile of ECT in bipolar mania, including a sample who received RUL-UB ECT. METHODS This naturalistic study retrospectively collected data in 33 patients who received ECT with concurrent antipsychotics for mania between October 1, 2014, and July 30, 2016. Electroconvulsive therapy was given using RUL-UB, brief-pulse right unilateral, or brief-pulse bitemporal approaches, dosed according to the patient's seizure threshold. The Brief Psychiatric Rating Scale (BPRS), Young Mania Rating Scale (YMRS) score, and the Montreal Cognitive Assessment (MoCA) were administered to patients before and after the ECT course. RESULTS For the whole sample, there was a significant improvement in BPRS (total score and manic subscale), YMRS, and MoCA total scores across the ECT treatment course. The overall BPRS response rate was 84%, and mean scores decreased from 42.1 (SD, 12.0) to 26.0 (SD, 4.0). The 13 patients who received RUL-UB ECT also showed significant improvement in BPRS, YMRS, and MoCA scores over the treatment course. CONCLUSIONS Electroconvulsive therapy in general and also specifically RUL-UB ECT were effective in treating mania and also led to global cognitive improvement.
Collapse
|
5
|
Seizure threshold increases can be predicted by EEG quality in right unilateral ultrabrief ECT. Eur Arch Psychiatry Clin Neurosci 2017; 267:795-801. [PMID: 28401340 DOI: 10.1007/s00406-017-0777-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/16/2017] [Indexed: 10/19/2022]
Abstract
Increases in seizure threshold (ST) over a course of brief pulse ECT can be predicted by decreases in EEG quality, informing ECT dose adjustment to maintain adequate supra-threshold dosing. ST increases also occur over a course of right unilateral ultrabrief (RUL UB) ECT, but no data exist on the relationship between ST increases and EEG indices. This study (n = 35) investigated if increases in ST over RUL UB ECT treatments could be predicted by a decline in seizure quality. ST titration was performed at ECT session one and seven, with treatment dosing maintained stable (at 6-8 times ST) in intervening sessions. Seizure quality indices (slow-wave onset, mid-ictal amplitude, regularity, stereotypy, and post-ictal suppression) were manually rated at the first supra-threshold treatment, and last supra-threshold treatment before re-titration, using a structured rating scale, by a single trained rater blinded to the ECT session being rated. Twenty-one subjects (60%) had a ST increase. The association between ST changes and EEG quality indices was analysed by logistic regression, yielding a significant model (p < 0.001). Initial ST (p < 0.05) and percentage change in mid-ictal amplitude (p < 0.05) were significant predictors of change in ST. Percentage change in post-ictal suppression reached trend level significance (p = 0.065). Increases in ST over a RUL UB ECT course may be predicted by decreases in seizure quality, specifically decline in mid-ictal amplitude and potentially in post-ictal suppression. Such EEG indices may be able to inform when dose adjustments are necessary to maintain adequate supra-threshold dosing in RUL UB ECT.
Collapse
|
6
|
Sidorov A, Mayur P. Rapid amelioration of severe manic episodes with right unilateral ultrabrief pulse ECT: a case series of four patients. Australas Psychiatry 2017; 25:10-12. [PMID: 27561846 DOI: 10.1177/1039856216663736] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this small case series is to describe four cases of severe mania, where ultrabrief pulse electroconvulsive therapy (ECT) was used as a primary mode of treatment. METHODS A retrospective file review was undertaken of four patients identified as having received ultrabrief pulse ECT for severe mania. The outcome measures for treatment efficacy were the Young Mania Rating Scale (YMRS) and Clinical Global Impression (CGI). RESULTS All the patients showed significant clinical improvement. A comparison of pre- and post-treatment YMRS and CGI scores showed a dramatic decrease in all four cases. However, one patient was shifted to brief pulse ECT due to inadequate response. CONCLUSIONS Ultrabrief pulse ECT may be an effective treatment in cases of severe mania. Due to the very small number of cases in the current case series, no specific conclusions regarding efficacy may be drawn; however, larger, controlled studies would be indicated.
Collapse
Affiliation(s)
- Alexey Sidorov
- Psychiatry Registrar, Forensic Hospital, Sydney, NSW, and; Honorary Medical Officer, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Prashanth Mayur
- Consultant Psychiatrist, Senior Staff Specialist, Mood Disorders Unit, Cumberland Hospital, Sydney, NSW, and; Discipline of Psychological Medicine, University of Sydney, Sydney, NSW, Australia
| |
Collapse
|