Effects of electroconvulsive therapy on cognitive functioning in patients with depression: protocol for a systematic review and meta-analysis

Multiomics and blood-based biomarkers of electroconvulsive therapy in severe and treatment-resistant depression: study protocol of the DetECT study

Electroconvulsive therapy (ECT) is commonly used to treat treatment-resistant depression (TRD). However, our knowledge of the ECT-induced molecular mechanisms causing clinical improvement is limited. To address this issue, we developed the single-center, prospective observational DetECT study ("Multimodal Biomarkers of ECT in TRD"; registered 18/07/2022, www.clinicalTrials.gov , NCT05463562). Its objective is to identify molecular, psychological, socioeconomic, and clinical biomarkers of ECT response in TRD. We aim to recruit n = 134 patients in 3 years. Over the course of 12 biweekly ECT sessions (± 7 weeks), participant blood is collected before and 1 h after the first and seventh ECT and within 1 week after the twelfth session. In pilot subjects (first n = 10), additional blood draws are performed 3 and 6 h after the first ECT session to determine the optimal post-ECT blood draw interval. In blood samples, multiomic analyses are performed focusing on genotyping, epigenetics, RNA sequencing, neuron-derived exosomes, purines, and immunometabolics. To determine clinical response and side effects, participants are asked weekly to complete four standardized self-rating questionnaires on depressive and somatic symptoms. Additionally, clinician ratings are obtained three times (weeks 1, 4, and 7) within structured clinical interviews. Medical and sociodemographic data are extracted from patient records. The multimodal data collected are used to perform the conventional statistics as well as mixed linear modeling to identify clusters that link biobehavioural measures to ECT response. The DetECT study can provide important insight into the complex mechanisms of ECT in TRD and a step toward biologically informed and data-driven-based ECT biomarkers.

Antidepressant Mechanism of Kaixinsan and Its Active Compounds Based on Upregulation of Antioxidant Thioredoxin

Objectives

Kaixinsan (KXS), a traditional Chinese medicine formula, has been demonstrated to be effective in the treatment of depression. The present study applied a network pharmacology approach to dig out the new targets and mechanism of action of KXS and the active compounds in the treatment of depression.

Methods

A network pharmacology approach based on public databases including ADME (absorption, distribution, metabolism, and excretion) evaluation, targets prediction, construction of networks, and molecule docking was used and validated the predicted new antioxidant targets and mechanisms in vitro. Based on an in vitro experiment, we verified the AKT1/Nrf2 pathway related to the thioredoxin (Trx) antioxidant mechanism.

Results

The present study sorted 31 pharmacologically active components (kaempferol, ginsenoside rh2, ginsenoside rh4, stigmasterol, etc.) through the ADME algorithm from KXS. 136 potential molecular targets (AKT1, TNF, IL-1b, JUN, ESR1, NOS3, etc.) were predicted, of which there were 69 targets clearly related to depression. By compound-depression targets (C-DTs) network constructed, and protein-protein interaction networks (PPI) and KEGG pathway enrichment analyzed, we identified active compounds mediating depression-related targets to exert synergism on the predictive AKT1/Nrf2 pathway related to thioredoxin (Trx) antioxidant mechanism and other inflammation-related signaling pathways as well as neurotransmitter related signaling pathways. In the H₂O₂ induced SH-SY5Y cell damage model, this showed kaempferol and ginsenoside rh2 could enhance the activity of the Trx system by upregulation of AKT1 to activate Nrf2 in vitro.

Conclusions

Taken together, by comprehensive systems pharmacology approach analysis, we found that KXS and its active compounds might exhibit antioxidant effects by stimulating the AKT1/Nrf2 pathway in the treatment of depression, which might shed new light on innovative therapeutic tactics for the new aspects for depression in traditional Chinese medicine in future studies.

Age-related heterogeneity revealed by disruption of white matter structural networks in patients with first-episode untreated major depressive disorder: WM Network In OA-MDD

The clinical treatment and prognosis of major depressive disorder (MDD) are limited by the high degree of disease heterogeneity. It is unclear whether there is a potential network mechanism for age-related heterogeneity. We aimed to uncover the heterogeneity of the white matter (WM) network at different ages of onset and its correlation with different symptom characteristics. 85 first-episode MDD patients and 84 corresponding healthy controls (HCs) were recruited and underwent diffusion tensor imaging scans. Structural network characteristics were analyzed using graph theory methods. We observed an accelerated age-related decline of the WM network in MDD patients compared with HCs. Distinct symptom-related networks were identified in three MDD groups with different onset-age. For early-onset MDD (18-29 years; EOD), higher guilt and loss of interest were correlated with the insula, and inferior parietal lobe which in default mode network and salience network. For mid-term-onset MDD (30-44 years; MOD), higher somatic symptoms were correlated with thalamus which in cortico-striatal-thalamic-cortical circuit. For later-onset MDD (45-60 years; LOD), poor sleep symptoms were correlated with the caudate in the basal ganglia, which suggests the cingulate operculum network in the control of sleep. These results supported a circuit-based heterogeneity associated with the age of onset in MDD. Understanding this circuit-based heterogeneity might help to develop a new target for clinical treatment strategies.

Clinicians’ Approach to Cognitive Impairment After Electroconvulsive Therapy: Current Situations and Challenges

Background: Electroconvulsive therapy (ECT) is one of the most effective treatments for severe refractory mental diseases. Widespread cognitive complications have affected the acceptance of this treatment. Despite current evidence of short-term cognitive impairment, long-term cognition consequences are less determined. Objectives: This study aimed to evaluate the clinical approach of psychiatrists, psychiatry residents, and nurses in psychiatric hospitals to the necessity, method, and frequency of cognitive assessment in candidate patients for ECT. Methods: In this descriptive study, 89 professional members of Roozbeh and Razi hospitals, Tehran, Iran, including nurses, residents, and faculty members of psychiatry, were selected using the purposive sampling method. The research questionnaires were sent, and 58 fulfilled questionnaires were sent back. The data were analyzed using central indicators and statistical dispersion. The designed questionnaire included the items related to the specialists’ views on the necessity of post-ECT cognitive evaluations, best batteries, frequency of performing the tests, and other related domains. Results: After close follow-up, 58 out of 89 participants completed the questionnaires, including 17 psychiatrists (29.3%), 20 nurses (34.5%), and 21 psychiatry residents (36.2%). The results were analyzed and interpreted in detail. The average work experience of respondents in the psychiatry field was 6.89 years (range: 1 - 25 years). Additionally, 97% of the specialists did not have any project in the ECT field and cognitive disorders. More than 80% of the participants believed that cognition evaluation is necessary for ECT-candidate patients; however, only 15% of the specialists referred patients for the assessment. Moreover, 43% of the experts recommended the Wechsler Memory Scale-Revised; nevertheless, nearly 26% of the experts recommended the Delis-Kaplan Executive Function System for the cognitive assessment of these patients. The Rey Auditory Verbal Learning Test was recommended by 20% of the experts. Nearly two-thirds of the respondents believed that a proper assessment should be carried out in about 30 minutes. More than 60% of the experts believed that patients should be evaluated before receiving the first session of ECT, and nearly one-third of the experts recommended only a post-ECT evaluation. More than half of the experts believed that ECT should be discontinued in case of severe cognitive impairment after ECT. Alternatively, less than 30% of the experts believed that it is necessary to make changes in the treatment dose and the interval between sessions. Furthermore, 80% of the experts recommended cognitive rehabilitation for patients with significant cognitive impairment after ECT; nonetheless, less than 20% of the experts recommended treatment with a cholinesterase inhibitor. Conclusions: A large percentage of patients do not undergo a comprehensive cognitive assessment after ECT, which is an important challenge in the estimation of post-ECT cognitive decline. There is a need to design inexpensive and sensitive tests for cognitive assessment. The test could measure different cognitive domains and be acceptable in terms of time. Due to the limited number of specialists working in this field, the frequency of assessment and treatment methods after the identification of cognitive disorders are heterogeneous. Therefore, it is required to design a native and practical guideline. These results could help the researchers design future studies to determine the best method of cognitive evaluation after ECT, appropriate batteries, recommended intervals, and treatment decisions after cognitive decline detection.

Cognitive effects of non-surgical brain stimulation for major depressive disorder: protocol for a systematic review and meta-analysis

INTRODUCTION

Non-surgical brain stimulation techniques may be considered as alternative or add-on treatments for patients with major depressive disorder who failed to respond to pharmacological interventions. Electroconvulsive therapy has been shown to be highly effective in reducing depressive symptoms but stakeholders remain concerned about adverse cognitive effects. Repetitive transcranial magnetic stimulation and transcranial direct current stimulation may be associated with more benign adverse effect profiles and may indeed improve certain cognitive functions such as memory and attention. To guide clinical decision-making, we will carry out a systematic review and meta-analysis of the cognitive effects of eight non-surgical brain stimulation techniques.

METHODS AND ANALYSIS

A systematic literature search of the Embase, PubMed/MEDLINE and PsycINFO databases, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and OpenGrey will be performed. We will include both randomised clinical trials which report on at least one cognitive measure post treatment as well as non-randomised trials and pre-post intervention studies. There are no restrictions to the type of cognitive outcome measures, except that the tests are standardised and psychometrically validated. The Revised Cochrane tool for assessing risk of bias in randomised trials (RoB 2.0) will be used to evaluate included trials. Pre-post studies will be evaluated using the quality assessment tool developed by the US National Heart, Lung and Blood Institute. Meta-analysis, meta-regression, subgroup and sensitivity analyses will be conducted where sufficient data are available.

ETHICS AND DISSEMINATION

No ethical approval is needed to conduct this work. The findings will be submitted for publication in peer-reviewed journals and presented at scientific meetings.

PROSPERO REGISTRATION NUMBER

CRD42018118850.

Radio electric asymmetric conveyer neuromodulation in depression, anxiety, and stress

BACKGROUND

The purpose of this study was to assess the efficacy of specific neuromodulation treatments performed with radio electric asymmetric conveyer (REAC) technology in the treatment of the symptomatic triad depression, anxiety, and stress by the use of a specific psychometric test such as the Depression Anxiety Stress Scale-42 items (DASS-42) version, which assesses simultaneously the severity of expression of this triad.

PATIENTS AND METHODS

The design of this study was planned to compare two populations that performed DASS-42 test twice within a similar period of time. The first population performed the first DASS test before the treatment and the second test about 3 months later, at the end of two specific REAC neuromodulation treatments, neuropostural optimization (NPO) and neuropsychophysical optimization (NPPO), that have previously shown an efficacy in the treatment of depression, anxiety and stress. The second population (untreated), used as the randomized control group, consisted of a similar group by gender and age, who performed the DASS-42 test in an online platform twice, with an interval of about 3 months between the first and second tests, similar to the interval between the two tests in the treated group.

RESULTS

The comparison between the treated group and the control group points out the REAC treatment efficacy in improving the quality of life. At the second DASS-42 test, self-administered about 3 months after the treatments, treated patients were positioned on average values of much milder severity in all the three clusters, depression, anxiety, and stress, while in untreated patients there was no significant difference between the mean values of the first and second DASS tests.

CONCLUSION

The results obtained in this study, evaluated with the DASS-42 test, confirm that REAC-NPO and REAC-NPPO neuromodulation treatments can be useful tools for the clinical treatment of depression, anxiety, and stress, as already proven by previous results evaluated with different psychometric tests.

A randomized clinical trial of adjunctive ketamine anesthesia in electro-convulsive therapy for depression

BACKGROUND

Electroconvulsive therapy (ECT) is a rapid acting and effective treatment for both major depressive disorder (MDD) and bipolar disorder (BP). Both propofol and ketamine are commonly used anesthetic agents but recent clinical studies suggest that ketamine has rapid-acting antidepressant properties, itself, at sub-anesthetic doses.

METHODS

A total of 77 inpatients (41 MDD and 36 BP) were randomly assigned to receive ECT with propofol (1mg/kg) anesthesia or with ketamine (0.5mg/kg) plus propofol (0.5mg/kg). Depressive symptoms were assessed with the 24-item Hamilton Depression Rating Scale (HAMD-24) and Montgomery-Asberg Rating Scale (MADRS), before and after 1, 2, 4, and 6 ECT treatments, and 1-4 weeks following the last treatment. The MATRICS Consensus Cognitive Battery (MCCB) was evaluated at baseline,after the sixth ECT, and 1-4 weeks following the final ECT. Adverse effects were assessed at baseline and 4 weeks after the last treatment.

RESULTS

There were no significant differences in depressive symptoms, MCCB performance, or adverse effects between the treatment groups at any time. The electrical dose required to generate seizures in the ketamine plus propofol group was lower than that of the propofol only group at every time point. The seizure energy index and seizure duration in the ketamine plus propofol group was higher and longer than those in the propofol only group.

LIMITATIONS

The diagnoses of MDD and BP were unevenly distributed across treatment groups.

CONCLUSIONS

Ketamine plus propofol anesthesia in the ECT treatment of MDD and BP was not superior on any measure to propofol alone.

Effect of Electroconvulsive Therapy on Cognitive Functions of Rats with Depression-Like Disorders Induced by Ultrasound Exposure

We studied the effect of electroconvulsive therapy on cognitive functions in rats with depression-like disorder caused by exposure to ultrasound of varying frequency (20-45 kHz). Object recognition and Morris water-maze tests revealed no negative effects of the therapy on memory. Moreover, positive effect of therapy was demonstrated that manifested in amelioration of memory disturbances in depression-like disorders in these behavioral tests. The results of this study do not support the idea about side effects of electroconvulsive therapy, in particular, development of transient amnesia, and are a prerequisite for a more thorough study of internal mechanisms of the effect of the therapy on cognitive sphere.

Switching From Age-Based Stimulus Dosing to Dose Titration Protocols in Electroconvulsive Therapy: Empirical Evidence for Better Patient Outcomes With Lower Peak and Cumulative Energy Doses

OBJECTIVE

The aim of this study was to test the proposition that adoption of a dose titration protocol may be associated with better patient outcomes, at lower treatment dose, and with comparable cumulative dose to that in patients treated using an age-based stimulus dosing protocol.

METHODS

This was an analysis of data assembled from archived records and based on cohorts of patients treated respectively on an age-based stimulus dosing protocol and on a dose titration protocol in the National Health Service in England.

RESULTS

We demonstrated a significantly better response in the patient cohort treated with dose titration than with age-based stimulus dosing. Peak doses were less and the total cumulative dose was less in the dose titration group than in the age-based stimulus dosing group.

CONCLUSIONS

Our findings are consistent with superior outcomes in patients treated using a dose titration protocol when compared with age-based stimulus dosing in a similar cohort of patients.

Electroconvulsive Therapy Hasn't Negative Effects on Short-Term Memory Function, as Assessed Using a Bedside Hand-Held Device

Electroconvulsive therapy (ECT) is effective in the treatment of treatment-resistant major depression. The fear of cognitive impairment after ECT often deters patients from choosing this treatment option. There is little reliable information regarding the effects of ECT on overall cognitive performance, while short-term memory deficits are well known but not easy to measure within clinical routines. In this pilot study, we examined ECT recipients' pre- and post-treatment performances on a digital ascending number tapping test. We found that cognitive performance measures exhibited good reproducibility in individual patients and that ECT did not significantly alter cognitive performance up to 2 hours after this therapy was applied. Our results can help patients and physicians make decisions regarding the administration of ECT. Digital measurements are recommended, especially when screening for the most common side effects on cognitive performance and short-term memory.

Acetylcholinesterase inhibitors for electroconvulsive therapy-induced cognitive side effects: a systematic review

OBJECTIVE

Electroconvulsive therapy (ECT) is an effective treatment for severe late-life depression; however, ECT-induced cognitive side effects frequently occur. The cholinergic system is thought to play an important role in the pathogenesis. We systematically reviewed the evidence for acetylcholinesterase inhibitors (Ache-I) to prevent or reduce ECT-induced cognitive side effects.

METHODS

A systematic search was performed in Pubmed, EMBASE, PsychINFO, and the Cochrane database to identify clinical trials investigating the effect of Ache-I on ECT-induced cognitive side effects. Key search terms included all synonyms for ECT and Ache-I. Risk of bias assessment was conducted by using the Cochrane Collaboration's tool.

RESULTS

Five clinical trials were eligible for inclusion. All studies focused on cognitive functioning as primary endpoint, but assessment of cognitive functioning varied widely in time point of assessment and in cognitive tests that were used. There was also great variety in study medication, route and time of administration and dosages, duration of drug administration, and ECT techniques. Finally, only two out of five studies were considered at low risk of bias. Despite the aforementioned shortcomings, without exception, all studies demonstrated significantly better cognitive performance in individuals treated with Ache-I.

CONCLUSIONS

Despite large heterogeneity in studies, Ache-I appear to have beneficial effects on ECT-induced cognitive side effects, supporting an association with the cholinergic system in ECT-induced cognitive impairment. Methodological sound studies controlling for putative confounders are warranted. Copyright © 2017 John Wiley & Sons, Ltd.

Exposure to violence, a risk for suicide in youths and young adults. A meta-analysis of longitudinal studies

OBJECTIVE

To assess the association and magnitude of the effect of early exposure to different types of interpersonal violence (IPV) with suicide attempt and suicide death in youths and young adults.

METHOD

We searched six databases until June 2015. Inclusion criteria were as follows: (1) assessment of any type of IPV as risk factor of suicide attempt or suicide: (i) child maltreatment [childhood physical, sexual, emotional abuse, neglect], (ii) bullying, (iii) dating violence, and (iv) community violence; (2) population-based case-control or cohort studies; and (3) subjects aged 12-26 years. Random models were used for meta-analyses (Reg: CRD42013005775).

RESULTS

From 23 682 articles, 29 articles with 143 730 subjects for meta-analyses were included. For victims of any IPV, OR of subsequent suicide attempt was 1.99 (95% CI: 1.73-2.28); for child maltreatment, 2.25 (95% CI: 1.85-2.73); for bullying, 2.39 (95% CI: 1.89-3.01); for dating violence, 1.65 (95% CI: 1.40-1.94); and for community violence, 1.48 (95% CI: 1.16-1.87). Young victims of IPV had an OR of suicide death of 10.57 (95% CI: 4.46-25.07).

CONCLUSION

Early exposure to IPV confers a risk of suicide attempts and particularly suicide death in youths and young adults. Future research should address the effectiveness of preventing and detecting early any type of IPV exposure in early ages.

Dexmedetomidine protects against learning and memory impairments caused by electroconvulsive shock in depressed rats: Involvement of the NMDA receptor subunit 2B (NR2B)-ERK signaling pathway

Cognitive impairment is a common adverse effect of electroconvulsive therapy (ECT) during treatment for severe depression. Dexmedetomidine (DEX), a sedative-anesthetic drug, is used to treat post-ECT agitation. However, it is not known if DEX can protect against ECT-induced cognitive impairments. To address this, we used chronic unpredictable mild stress (CUMS) to establish a model of depression for ECT treatment. Our Morris water maze and sucrose preference test results suggest that DEX alleviates ECT-induced learning and memory impairments without altering the antidepressant efficacy of ECT. To further investigate the underlying mechanisms of DEX, hippocampal expression of NR2B, p-ERK/ERK, p-CREB/CREB, and BDNF were quantified by western blotting. These results show that DEX suppresses over-activation of NR2B and enhances phosphorylation of ERK1/2 in the hippocampus of ECT-treated depressed rats. Furthermore, DEX had no significant effect on ECT-induced increases in p-CREB and BDNF. Overall, our findings suggest that DEX ameliorates ECT-induced learning and memory impairments in depressed rats via the NR2B-ERK signaling cascade. Moreover, CREB/BDNF seems not appear to participate in the cognitive protective mechanisms of DEX during ECT treatment.

Mood and neuropsychological effects of different doses of ketamine in electroconvulsive therapy for treatment-resistant depression

BACKGROUND

Treatment-resistant depression (TRD) is a growing clinical challenge. Electroconvulsive therapy (ECT) is an effective tool for TRD treatment. However, there remains a subset of patients who do not respond to this treatment with common anesthetic agent. Ketamine, a noteworthy anesthetic agent, has emerged as an augmentation to enhance the antidepressant efficacy of ECT. Trials of i.v. ketamine in TRD indicated dose-related mood enhancing efficacy. We aimed to explore anesthetic and subanesthetic concentrations of ketamine in ECT for TRD with respect to their impact on mood and neuropsychological effects.

METHODS

Ninety TRD patients (36 males, 54 females; average age, 30.6 years old) were randomly assigned to receive either ketamine (0.8mg/kg) (n=30), subanesthetic ketamine (0.5mg/kg) plus propofol (0.5mg/kg) (n=30) or propofol (0.8mg/kg) (n=30) as an anesthetic and underwent 8 ECT sessions. The primary outcome measures were the 17-item Hamilton Depression Rating Scale (HDRS-17), cognitive assessments and seizure parameters.

RESULTS

The ketamine group had an earlier improvement in HDRS-17, longer seizure duration, lower electric quantity, a higher remission rate, and a lower degree of executive cognitive impairment compared to the ketamine+propofol and propofol groups. The ketamine+propofol group showed earlier improvement in the HDRS-17, a longer seizure duration and a different seizure energy index when compared to the propofol group.

LIMITATIONS

The postoperative dissociative side effect was not assessed.

CONCLUSIONS

Both anesthetic and subanesthetic concentrations of ketamine have rapid mood enhancing actions in ECT for TRD, while anesthetic concentrations results in larger magnitudes of antidepression and cognitive protection. ECT with ketamine anesthesia might be an optimized therapy for patients with TRD.

A Bayesian framework systematic review and meta-analysis of anesthetic agents effectiveness/tolerability profile in electroconvulsive therapy for major depression

The aim of this study was to assess the efficacy and tolerability/acceptability of 6 anesthetic agents in ECT for depressive disorders. We systematically reviewed 14 double-blind randomized controlled trials (610 participants). Efficacy was measured by the mean scores on validated depression scales at 6 ECT (or the nearest score if not available), number of responders at the end of treatment and seizure duration. The acceptability was measured by the proportion of patients who dropped out of the allocated treatment, and the tolerability by the number of serious adverse events and post-treatment cognition assessment. After excluding the trials responsible for heterogeneity, depression scores of patients who were administered methohexital were found to be significantly more improved than those who received propofol (p = 0.001). On the contrary, those who were administered propofol had lower depression scores than those with thiopental at the end of treatment (p = 0.002). Compared to propofol, methohexital was found to be significantly associated with higher seizure duration (p = 0.018). No difference was found for the acceptability profile (all p > 0.05). In summary, ketamine and methohexital may be preferred to propofol or thiopental in regard of effectiveness in depression scores and increased seizure duration. Further studies are warranted to compare ketamine and methohexital.