Is old-fashioned electroconvulsive therapy more efficacious? A randomised comparative study of bilateral brief-pulse and bilateral sine-wave treatments

The benefits and costs of changing treatment technique in electroconvulsive therapy due to insufficient improvement of a major depressive episode

BACKGROUND

Electroconvulsive therapy (ECT) technique is often changed after insufficient improvement, yet there has been little research on switching strategies.

OBJECTIVE

To document clinical outcome in ECT nonresponders who were received a second course using high dose, brief pulse, bifrontotemporal (HD BP BL) ECT, and compare relapse rates and cognitive effects relative to patients who received only one ECT course and as a function of the type of ECT first received.

METHODS

Patients were classified as receiving Weak, Strong, or HD BP BL ECT during three randomized trials at Columbia University. Nonresponders received HD BP BL ECT. In a separate multi-site trial, Optimization of ECT, patients were randomized to right unilateral or BL ECT and nonresponders also received further treatment with HD BP BL ECT.

RESULTS

Remission rates with a second course of HD BP BL ECT were high in ECT nonresponders, approximately 60% and 40% in the Columbia University and Optimization of ECT studies, respectively. Clinical outcome was independent of the type of ECT first received. A second course with HD BP BL ECT resulted in greater retrograde amnesia immediately, two months, and six months following ECT.

CONCLUSIONS

In the largest samples of ECT nonresponders studied to date, a second course of ECT had marked antidepressant effects. Since the therapeutic effects were independent of the technique first administered, it is possible that many patients may benefit simply from longer courses of ECT. Randomized trials are needed to determine whether, when, and how to change treatment technique in ECT.

Electroconvulsive therapy machines

Electroconvulsive therapy (ECT) is a long established form of treatment for specific, serious mental disorders, but one which is still surrounded by much misunderstanding and fear. The use of electrical current administered to the brain to ‘treat’ illness remains a barbaric concept to many people. Much research has been conducted to establish the efficacy of ECT, which is now widely accepted. However, the working principles of the ECT machine itself are little understood, and more research remains to be done to establish, more scientifically, which is the ‘best’ way to administer the electrical stimulus. With the recent introduction of the concept of “stimulus dosing” (for a review see Lock, 1994), the need to be aware of the ECT machines available and their abilities and limitations is important.

Predictors of Postdeployment Functioning in Combat-Exposed U.S. Military Veterans

Posttraumatic stress disorder (PTSD) and sequelae of mild traumatic brain injury (mTBI) are presumed to contribute to reintegration difficulties in combat-exposed veterans. Yet their relative impacts on postdeployment functioning are not well understood. The current study used structural equation modeling (SEM) to clarify the extent to which symptoms of internalizing disorders (e.g., depression, anxiety), mTBI symptoms, and cognitive performance are associated with functional impairment in 295 combat-exposed veterans. SEM results showed that internalizing symptoms most significantly predicted functional impairment (r = 0.72). Blast mTBI and cognitive performance were associated with internalizing (r = 0.24 and -0.25, respectively), but functional impairment was only modestly related to cognition (r = -0.17) and unrelated to mTBI. These results indicate that internalizing symptoms are the strongest predictor of functioning in trauma-exposed veterans, exceeding the effects of mTBI and cognitive performance. This evidence supports prioritizing interventions that target internalizing psychopathology to improve functioning in cases of co-occurring PTSD and mTBI.

Two decades of an indigenously developed brief-pulse electroconvulsive therapy device: A review of research work from National Institute of Mental Health and Neurosciences

In 1993, a device to administer brief-pulse electroconvulsive therapy was indigenously developed through collaboration between the National Institution for Quality and Reliability and the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India. The additional feature of computerized recording of the electroencephalograph and electrocardiograph for both online and offline use had substantial clinical and research implications. Over the past two decades, this device has been used extensively in different academic and nonacademic settings. A considerable body of research with clinical and heuristic interest has also emanated using this device. In this paper, we present the development of this device and follow it up with a review of research conducted at NIMHANS that validate the features and potentials of this device.

ECT: shocked beyond belief

OBJECTIVE

The aim of this paper is to consider electroconvulsive therapy (ECT) in the 21st century and whether it should be a treatment of last resort from the perspective of someone who has received the treatment in recent years.

CONCLUSION

It seems that informed consent, the introduction of advance directives and the improved delivery of ECT have done little to ease people's fear, with a lot of people still believing ECT to be an extreme form of treatment and only a last resort option. The idea of any treatment being considered 'last resort' in mental health care gives the impression that it is the most radical and worst treatment available - thus we leave it until last to try. Yet for many people, including myself, the treatment is a valid and preferred option with minimal side effects.

The cognitive effects of electroconvulsive therapy in community settings

Despite ongoing controversy, there has never been a large-scale, prospective study of the cognitive effects of electroconvulsive therapy (ECT). We conducted a prospective, naturalistic, longitudinal study of clinical and cognitive outcomes in patients with major depression treated at seven facilities in the New York City metropolitan area. Of 751 patients referred for ECT with a provisional diagnosis of a depressive disorder, 347 patients were eligible and participated in at least one post-ECT outcome evaluation. The primary outcome measures, Modified Mini-Mental State exam scores, delayed recall scores from the Buschke Selective Reminding Test, and retrograde amnesia scores from the Columbia University Autobiographical Memory Interview-SF (AMI-SF), were evaluated shortly following the ECT course and 6 months later. A substantial number of secondary cognitive measures were also administered. The seven sites differed significantly in cognitive outcomes both immediately and 6 months following ECT, even when controlling for patient characteristics. Electrical waveform and electrode placement had marked cognitive effects. Sine wave stimulation resulted in pronounced slowing of reaction time, both immediately and 6 months following ECT. Bilateral (BL) ECT resulted in more severe and persisting retrograde amnesia than right unilateral ECT. Advancing age, lower premorbid intellectual function, and female gender were associated with greater cognitive deficits. Thus, adverse cognitive effects were detected 6 months following the acute treatment course. Cognitive outcomes varied across treatment facilities and differences in ECT technique largely accounted for these differences. Sine wave stimulation and BL electrode placement resulted in more severe and persistent deficits.

Electroconvulsive therapy for schizophrenia

BACKGROUND

Electroconvulsive therapy (ECT) involves the induction of a seizure for therapeutic purposes by the administration of a variable frequency electrical stimulus shock via electrodes applied to the scalp. The effects of its use in people with schizophrenia are unclear.

OBJECTIVES

To determine whether electroconvulsive therapy (ECT) results in clinically meaningful benefit with regard to global improvement, hospitalisation, changes in mental state, behaviour and functioning for people with schizophrenia, and to determine whether variations in the practical administration of ECT influences outcome.

SEARCH STRATEGY

We undertook electronic searches of Biological Abstracts (1982-1996), EMBASE (1980-1996), MEDLINE (1966-2004), PsycLIT (1974-1996),SCISEARCH (1996) and the Cochrane Schizophrenia Group's Register (July 2004). We also inspected the references of all identified studies and contacted relevant authors.

SELECTION CRITERIA

We included all randomised controlled clinical trials that compared ECT with placebo, 'sham ECT', non-pharmacological interventions and antipsychotics and different schedules and methods of administration of ECT for people with schizophrenia, schizoaffective disorder or chronic mental disorder.

DATA COLLECTION AND ANALYSIS

Working independently, we selected and critically appraised studies, extracted data and analysed on an intention-to-treat basis. Where possible and appropriate we calculated risk ratios (RR) and their 95% confidence intervals (CI) with the number needed to treat (NNT). For continuous data Weighted Mean Differences (WMD) were calculated. We presented scale data for only those tools that had attained pre-specified levels of quality. We also undertook tests for heterogeneity and publication bias.

MAIN RESULTS

This review includes 26 trials with 50 reports. When ECT is compared with placebo or sham ECT, more people improved in the real ECT group (n=392, 10 RCTs, RR 0.76 random CI 0.59 to 0.98, NNT 6 CI 4 to 12) and though data were heterogeneous (chi-square 17.49 df=9 P=0.04), its impact on variability of data was not substantial (I-squared 48.5%). There was a suggestion that ECT resulted in less relapses in the short term than sham ECT (n=47, 2 RCTs, RR fixed 0.26 CI 0.03 to 2.2), and a greater likelihood of being discharged from hospital (n=98, 1 RCT, RR fixed 0.59, CI 0.34 to 1.01). There is no evidence that this early advantage for ECT is maintained over the medium to long term. People treated with ECT did not drop out of treatment earlier than those treated with sham ECT (n=495, 14 RCTs, RR fixed 0.71 CI 0.33 to 1.52, I-squared 0%). Very limited data indicated that visual memory might decline after ECT compared with sham ECT (n=24, 1 RCT, WMD -14.0 CI -23 to -5); the results of verbal memory tests were equivocal. When ECT is directly compared with antipsychotic drug treatments (total n=443, 10 RCTs) results favour the medication group (n=175, 3 RCTs, RR fixed 'not improved at the end of ECT course' 2.18 CI 1.31 to 3.63). Limited evidence suggests that ECT combined with antipsychotic drugs results in greater improvement in mental state (n= 40, 1 RCT, WMD, Brief Psychiatric Rating Scale -3.9 CI - 2.28 to -5.52) than with antipsychotic drugs alone. One small study suggested more memory impairment after a course of ECT combined with antipsychotics than with antipsychotics alone (n=20, MD serial numbers and picture recall -4.90 CI -0.78 to -9.02), though this proved transient. When continuation ECT was added to antipsychotic drugs, the combination was superior to the use of antipsychotics alone (n=30, WMD Global Assessment of Functioning 19.06 CI 9.65 to 28.47), or CECT alone (n=30, WMD -20.30 CI -11.48 to -29.12). Unilateral and bilateral ECT were equally effective in terms of global improvement (n=78, 2 RCTs, RR fixed 'not improved at end of course of ECT' 0.79 CI 0.45 to 1.39). One trial showed a significant advantage for 20 treatments over 12 treatments for numbers globally improved at the end of the ECT course (n=43, RR fixed 2.53 CI 1.13 to 5.66).

AUTHORS' CONCLUSIONS

The evidence in this review suggests that ECT, combined with treatment with antipsychotic drugs, may be considered an option for people with schizophrenia, particularly when rapid global improvement and reduction of symptoms is desired. This is also the case for those with schizophrenia who show limited response to medication alone. Even though this initial beneficial effect may not last beyond the short term, there is no clear evidence to refute its use for people with schizophrenia. The research base for the use of ECT in people with schizophrenia continues to expand, but even after more than five decades of clinical use, there remain many unanswered questions regarding its role in the management of people with schizophrenia.

Efficacy of ECT in depression: a meta-analytic review

This study analyzed the efficacy of electroconvulsive therapy (ECT) in depression by means a meta-analytic review of randomized controlled trials that compared ECT with simulated ECT or placebo or antidepressant drugs and by a complementary meta-analytic review of nonrandomized controlled trials that compared ECT with antidepressants drugs. The review revealed a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus placebo, ECT versus antidepressants in general, ECT versus TCAs and ECT versus MAOIs. The nonrandomized controlled trials also revealed a significant statistical difference in favor of ECT when confronted with antidepressants drugs. Data analyzed suggest that ECT is a valid therapeutic tool for treatment of depression, including severe and resistant forms.

A meta-analysis of electroconvulsive therapy efficacy in depression

Recently published controlled studies comparing electroconvulsive therapy (ECT) with other treatments for depression offer the opportunity to perform a meta-analysis of ECT in depression. Fifteen studies were identified which fulfilled the inclusion criteria. From these controlled trials, 20 effect sizes of ECT were calculated. The speed of action during the course and the efficacy after a full course of ECT were explored. The efficacy of sine wave and brief pulse machines were compared. The comparison between ECT and four other comparative treatments was made. Predictive variables were explored using homogeneity tests. ECT was shown to be superior after a full course. The funnel plot showed the absence of publication bias. There was no exaggeration of effect size in the lower quality trials. No evidence was found for a superior speed of action of ECT or for a difference in efficacy between sine wave and brief pulse stimulation. ECT was shown to be superior to medication and simulated ECT. Some evidence was found that psychosis predicted better response to ECT.

Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis

BACKGROUND

We aimed to review published work for the efficacy and safety of electroconvulsive therapy (ECT) with simulated ECT, ECT versus pharmacotherapy, and different forms of ECT for patients with depressive illness.

METHODS

We designed a systematic overview and meta-analysis of randomised controlled trials and observational studies. We obtained data from the Cochrane Collaboration Depressive Anxiety and Neurosis and Schizophrenia Group Controlled trial registers, Cochrane Controlled Trials register, Biological Abstracts, CINAHL, EMBASE, LILACS, MEDLINE, PsycINFO, and SIGLE, reference lists, and specialist textbooks. Our main outcome measures were depressive symptoms, measures of cognitive function, and mortality.

FINDINGS

Meta-analysis of data of short-term efficacy from randomised controlled trials was possible. Real ECT was significantly more effective than simulated ECT (six trials, 256 patients, standardised effect size [SES] -0.91, 95% CI -1.27 to -0.54). Treatment with ECT was significantly more effective than pharmacotherapy (18 trials, 1144 participants, SES -0.80, 95% CI -1.29 to -0.29). Bilateral ECT was more effective than unipolar ECT (22 trials, 1408 participants, SES -0.32, 95% CI -0.46 to -0.19).

INTERPRETATION

ECT is an effective short-term treatment for depression, and is probably more effective than drug therapy. Bilateral ECT is moderately more effective than unilateral ECT, and high dose ECT is more effective than low dose.

Electroconvulsive therapy for schizophrenia

BACKGROUND

Electroconvulsive therapy (ECT) involves the induction of a seizure (fit) for therapeutic purposes by the administration of a variable frequency electrical stimulus shock via electrodes applied to the scalp. The effects of its use in people with schizophrenia are unclear.

OBJECTIVES

To determine whether electroconvulsive therapy (ECT) results in clinically meaningful benefit with regard to global improvement, hospitalisation, changes in mental state, behaviour and functioning for people with schizophrenia, and whether variations in the practical administration of ECT influences outcome.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1996), EMBASE (1980-1996), MEDLINE (1966-2001), PsycLIT (1974-1996),SCISEARCH (1996) and the Cochrane Schizophrenia Group's Register (July 2001) were undertaken. The references of all identified studies were also inspected and authors contacted.

SELECTION CRITERIA

All randomised controlled clinical trials that compared ECT with placebo, 'sham ECT', non-pharmacological interventions and antipsychotics, and different schedules and methods of administration of ECT for people with schizophrenia, schizoaffective disorder or chronic mental disorder.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data, relative risks (RR) were estimated, with the 95% confidence intervals (CI). Where possible, the number needed to treat statistic (NNT) was calculated. Analysis was by intention-to-treat. Normal continuous data was summated using the weighted mean difference (WMD). Scale data was presented for only those tools that had attained pre-specified levels of quality. Tests of heterogeneity and for publication bias were undertaken.

MAIN RESULTS

This review includes 24 trials with 46 reports. When ECT is compared with placebo or sham ECT, fewer people remain unimproved in the real ECT group (n=400, RR fixed 'not globally improved in the short term' 0.77 CI 0.6 to 0.9, chi-square 13.46 df=8 p=0.1). Removal of the one study with clearly heterogeneous results causes a change in the findings (n=380, 8 RCTs, RR fixed 0.83 CI 0.7 to 1.01), as does removal of a clinically heterogeneous trial (n=370, 8 RCTs, RR fixed 0.74 CI 0.6 to 0.9, chi-square 10.97 df=7 p=0.14). There was a suggestion that ECT resulted in less relapses than sham ECT (n=47, 2 RCTs, RR fixed 0.26 CI 0.03 to 2.2), and a greater likelihood of being discharged from hospital (n=98, 1 RCT, RR fixed 0.59, CI 0.34 to 1.01). There is no evidence that this early advantage for ECT is maintained over the medium to long term. People treated with ECT did not drop out of treatment earlier than those treated with sham ECT (n=495, 14 RCTs, RR fixed 0.71 CI 0.33 to 1.52). Very limited data indicated that visual memory might decline after ECT compared with sham ECT (n=24, 1 RCT, WMD -14.0 CI -23 to -5); the results of verbal memory tests were equivocal. When ECT is directly compared with antipsychotic drug treatment (total n=419, 8 RCTs), results favour the medication group (n=175, 3 RCTs, RR fixed 'not improved at the end of ECT course' 2.18 CI 1.3 to 3.6). One small study suggested more memory impairment after a course of ECT combined with antipsychotics than with antipsychotics alone (n=20, MD serial numbers and picture recall -4.90 CI -0. 8 to -9), though this proved transient. When continuation ECT was added to antipsychotic drugs, the combination was superior to the use of antipsychotics alone (n=30, WMD Global Assessment of Functioning 19.1 CI 9.7 to 28.5), or CECT alone (n=30, WMD -20.3 CI -11.5 to -29.1). Unilateral and bilateral ECT were equally effective in terms of global improvement (n=78, 2 RCTs, RR fixed 'not improved at end of course of ECT' 0.79 CI 0.5 to 1.4). One trial showed a significant advantage for 20 treatments over 12 treatments for numbers globally improved at the end of the ECT course (n=43, RR fixed 2.53 CI 1.1 to 5.7).

REVIEWER'S CONCLUSIONS

There is no evidence to clearly refute the use of ECT for people with schizophrenia. There is some limited evidence to support its use, particularly combined with antipsychotic drugs for those with schizophrenia who show limited response to medication alone. The research base for the use of ECT in people with schizophrenia is growing but, even after more than five decades of clinical use, is still inadequate.

"Side effects" of ECT are mainly depressive phenomena and are independent of age

BACKGROUND

The aetiology of reported side effects of electroconvulsive therapy (ECT) is unclear. We examined the interaction of depression and age on adverse neuropsychological and putative side effects of ECT.

METHOD

Inpatients (N=81; median age 70 years) with major depression were assessed prospectively pre-ECT, immediately post-ECT and 1-3 years later. Patients were administered the Hamilton Rating Scale for Depression (HRSD), the Global Assessment of Functioning scale (GAF) and neuropsychological tests from the Wechsler Memory Scale. Side effects and total burden scores were rated pre- and post-treatment.

RESULTS

HRSD and GAF scores improved with treatment after ECT, but the prevalence and total burden of side effects were unchanged. Side effect burden was related to depression level before and after ECT. Improvement in depression correlated with reduction in side effect burden. There was a significant decline in side effect burden after controlling for change in depression. Patients' scores on neuropsychological measures did not appear to change after ECT or between pre-ECT and follow-up. Re-analysis, allowing for age, chronicity of depression, medication use and development of dementia, did not alter the findings.

LIMITATIONS

lack of a control group, lack of information on ECT technique, incomplete data sets and limited neuropsychological testing.

CONCLUSIONS

ECT, an effective treatment for depression, does not cause significant side effects or neuropsychological impairment, which are more likely to be depressive phenomena. ECT appears to be safe for old (> or =65 years) and very old (> or =75 years) patients, who do not appear to be more susceptible to adverse effects.

Is there a delay in the onset of the antidepressant effect of electroconvulsive therapy?

The severity of depression in 11 drug-free unipolar patients diagnosed with definite major depressive disorder was assessed using the Hamilton Rating Scale for Depression during a course (5-10 treatments) of bilateral electroconvulsive therapy (ECT). The degree of improvement after three treatments of ECT was six times greater than the improvement that occurred over the remainder of the course. Although depressed patients who recover with ECT require repeated treatments, the treatments early in a course of ECT can have marked antidepressant effect.