The present status of electroconvulsive therapy: a systematic review

The impact of electroconvulsive therapy on the spatial QRS-T angle and cardiac troponin T concentration in psychiatric patients

Background

Electroconvulsive therapy (ECT) is an effective treatment method used in psychiatry; however, its cardiac safety has not been clearly demonstrated. The aim of the study was evaluation of the ECT effects on the myocardium based on troponin T concentrations and the following ECG parameters: the spatial QRS-T angle (QRS-TA), QRS duration (QRSd) and the corrected QT interval (QTc).

Methods

In the study 44 patients (12 female and 32 male) were enrolled diagnosed with schizophrenia (n = 21) and major depressive disorders (n = 23), according to the DSM-IVR criteria. All cases were undergoing ECT procedures. The mean age of the patients was 36.9±16 years (range: 18–74). Resting ECG was recorded before performing ECG and 1 hour after. The spatial QRS-TA was reconstructed from 12-lead ECG using the inverse Dower method. Troponin T concentration was assessed before the procedure and 6 hours after ECT.

Results

No significant changes to troponin T concentrations were observed during the ECT series. The pre-ECT value of the spatial QRS-TA was 41.1±18.9°. The follow-up examinations did not reveal any significant increase of this parameter (p = 0.09) in any of the consecutive measurements. There were no significant changes in the QTc interval duration or the QRS complex duration demonstrated before the third, fifth and last procedure in the cycle (p>0.05). No significant changes to troponin T concentrations were observed during the ECT series.

Conclusions

Our findings indicate a lack of negative ECT effects on the risk of adverse cardiovascular events measured by the spatial QRS-T angle and cardiac troponin T concentration.

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.

The sham ECT literature: implications for consent to ECT

The author reviewed the placebo-controlled literature on electroconvulsive therapy (ECT) for depression. No study demonstrated a significant difference between real and placebo (sham) ECT at 1 month posttreatment. Many studies failed to find a difference between real and sham ECT even during the period of treatment. Claims in textbooks and review articles that ECT is effective are not consistent with the published data. A large, properly designed study of real versus sham ECT should be undertaken. In the absence of such a study, consent forms for ECT should include statements that there is no controlled evidence demonstrating any benefit from ECT at 1 month posttreatment. Consent forms should also state that real ECT is only marginally more effective than placebo.

Changes in private sector electroconvulsive treatment in Australia

OBJECTIVES

This paper reports on changes, over time and between states, in the use of electroconvulsive therapy (ECT) in the private psychiatric sector in Australia between 1984 and 2004.

METHOD

Data for ECT services, and all specialist psychiatry services provided under the Medicare system, have been analysed in absolute numbers and as utilization rates.

RESULTS

Changes in the use of ECT over time are different from other services provided by private psychiatrists. As in other countries, the use of ECT initially declined in period studied but has increased in recent years. In addition, there is a clear pattern of differential use of ECT between the states and territories.

CONCLUSIONS

This descriptive study cannot 'explain' the results obtained: other data, incorporated into an explanatory model using regression analysis, are needed to determine the factors underlying the utilization patterns obtained in this study. Thus, further work is needed. Furthermore, it is important to analyse data at a lower level of geographical aggregation than that of the state/territory: this (state/territory) aggregation conceals differences in utilization between metropolitan, minor city, rural and remote regions of the country.

Considering the major mental disorders as clinical expressions of periodic pathological oscillations of the overall operating mode of brain function

The consideration of the collective significance of the shared characteristics and overlaps in the clinical expression and pharmacological responses of the major mental disorders (namely, schizophrenia, bipolar disorders, obsessive compulsive disorder, anxieties/phobias, borderline syndrome and possibly others) supports the following: (1) These disorders have a common, initial neurodevelopmental origin. (2) They occur probabilistically on some of "at-risk" individuals whose pre-existing, extreme, temperamental/structural variance confers vulnerability for such occurrence. (3) Lastly, each of these syndromes can be considered as a clinical expression of oscillations (i.e., a switch to a pathologically ordered phase) of the overall, common operating mode of brain function. This mode based on a particular-for-our-brain, emergent quality of complexity, normally ensures the synchrony, coordination, subtlety and robust flexibility in the expression of the components of each of the various higher faculties of the brain, namely, the faculty of: (1) mood modulation; (2) coordination of feelings, thoughts and the responses to the external world; and (3) keeping constrain and limited but appropriate input of primitive drives. The conclusions in this paper have important ramifications in rethinking the current nosological procrustean flawed classification and the neurodevelopmental origin of the major mental disorders as well as the biases shown in selecting subjects for research. It also opens opportunities in the future development of novel, effective, economical and harmless therapies that will restore and maintain the normal phase of the operating mode of brain function. For example, the patient can wear an appropriate electronic device that sends a particular type of signal to the brain which will affect remission and prevent relapses without harm. We can thus avoid the use of pharmacological agents which have limited effectiveness, severe, long-term side-effects and financial burden to the patient.

Electroconvulsive therapy practice in Western Australia

OBJECTIVES

Despite the continued wide use of electroconvulsive therapy (ECT), there is little empirical research documenting numbers and characteristics of recipients of ECT, or the number of ECT administrations in various jurisdictions. This study aimed to further develop an Australian perspective on the practice of ECT, with particular emphasis on its use with children and older adults.

METHODS

The Mental Health Information System of Western Australia (WA) and records from State psychiatric hospitals were examined for data on ECT use over the period from 1997 to 2001.

RESULTS

Most Western Australia recipients of ECT were adult women who were diagnosed with affective disorders. Although the number of ECT recipients rose dramatically each year, ECT usage appeared to be a constant proportion of the psychiatric population in WA during a 5-year period in association with increased numbers of psychiatric patients.

CONCLUSIONS

Use of ECT in WA was at a lower rate than previously reported for Victoria, and notably lower than for older adults in NSW. As in most recent surveys, affective disorders were the most common diagnosis among recipients of ECT. The creation of a more comprehensive State ECT register is recommended to allow more accurate estimations of the frequency of ECT administrations in future, and facilitate more effective and efficient monitoring of ECT practice.

Patterns of electroconvulsive therapy use in Spain

OBJECTIVE

To describe the utilization, geographical variations and adaptation of ECT in the Spanish context.

METHOD

A cross-sectional study, involving a questionnaire delivered to all hospitals with a Psychiatry Unit (PU) in Spain included in the National Hospitals Catalogue (N = 233). A descriptive analysis was made of the answers to the different questions, using an adequate denominator in each case: all PUs (n = 233), those units that prescribe and apply ECT (n = 174), or only those that apply the technology (n = 108).

RESULTS

All PUs completed the questionnaire. Fifty-nine units (25.3%) neither prescribed nor applied ECT, while 108 (46.4%) prescribed and applied the technology, and 66 PUs (28.3%) only prescribed ECT. Those units with training responsibilities for psychiatry residents or pregraduate students, and those with a larger number of beds, were more inclined to apply ECT. The estimated ECT applied in the preceding 12 months totaled 2435 with an annual rate per 10,000 inhabitants of 0.61, and a range per Spanish Autonomous Community of 0.28-16.59.

CONCLUSIONS

We now know a reliable rate and characteristics of the use of ECT in Spain, and the attitudes and opinion of PUs Spanish psychiatrists about it. We found a very important variability in ECT application rates among Autonomous Communities.

Electroconvulsive therapy and determination of cerebral dominance

Electroconvulsive therapy (ECT) often results in a number of short- and long-time side effects including memory impairment for past and current events, which can last for several months after ECT treatment. It has been suggested that unilateral ECT (uECT) with electrodes placed over the non-dominant (typically right) hemisphere significantly reduces side effects, especially memory disturbances. It is important to note that cerebral dominance equates to speech dominance and avoiding this area of the brain also reduces speech dysfunction after ECT. Traditionally, the routine clinical determination of cerebral dominance has been through the assessment of hand, foot and eye dominance, which is an easy and inexpensive approach that, however, does not ensure accuracy. This review of literature on different methods and techniques for determination of cerebral dominance and provides evidence that functional transcranial Doppler sonography (fTCD) represents a valid and safe alternative to invasive techniques for identifying speech lateralisation. It can be concluded that fTCD, notwithstanding its costs, could be used as a standard procedure prior to uECT treatment to determine cerebral dominance, thereby further reducing cognitive side-effects of ECT and possibly making it more acceptable to both patients and clinicians.

Enhancing outcomes in the management of treatment resistant depression: a focus on atypical antipsychotics

Clinical trials indicate that over 50% of depressed patients show an inadequate response to antidepressant therapy, and that incomplete recovery from major depressive disorder (MDD) increases the risk of chronicity and recurrence. Recovery, complete remission of symptoms, and a return to baseline psychosocial function, should be the goal of therapy. Poor response to adequate antidepressant treatment has been termed treatment resistant depression (TRD). Issues such as adherence, missed diagnosis of psychotic depression, bipolar disorder, or comorbid anxiety must be investigated as reasons why patients have not responded to initial therapeutic strategies. Beyond ensuring optimal use of the index antidepressant, treatment strategies for TRD include switching to another antidepressant, and augmentation or combination with two or more agents. Since little comparative data exist it is important to consider side-effect burden, partial response, and previous medication history when deciding between strategies. In patients with TRD, adding or augmenting with lithium, tri-iodothyronine or atypical antipsychotics have demonstrated benefits. Augmentation with atypical antipsychotics, including risperidone, olanzapine, ziprasidone, and quetiapine, show promising results in terms of improving remission rates. Other interventions, including non-pharmacologic strategies and investigational physical treatments, have demonstrated some benefits, but availability and patient preference should also be considered. With today's therapeutic alternatives, full remission of depression is an attainable goal. For some patients, combination and augmentation strategies earlier in treatment may increase the likelihood of remission.

Epileptiform spikes desynchronize and diminish fast (gamma) activity of the brain. An "anti-binding" mechanism?

Fast (20-100 Hz) rhythms of electrical activity of the brain have been suggested to be important for perception and cognition providing a mechanism for temporal binding of neural activities underlying mental representations. Also, fast rhythms often precede epileptiform discharges in patients and some experimental models. Generalized slow (2-3 Hz) spike activity after systemic kainic acid (KA) in the rat has been shown to be preceded by intense gamma activity. A relationship between the intensified gamma rhythms and the subsequent spike activity was studied during kainate-induced acute epileptogenesis. Power, multiple coherence and phase were analyzed at frequencies 1-100 Hz in the EEG recorded from the hippocampal-neocortical structures of the rat. Gamma rhythms, extremely intense and highly coherent at the onset of discharges, were followed by a slow rhythm of epileptiform spikes/sharp waves. During this spike activity and immediately afterwards, the gamma power and coherence were significantly decreased. These data show an antagonism between gamma rhythms and spike activity and ability of the latter to desynchronize and suppress the former. They are supportive to the hypothesis that epileptiform spike activity may result from the extreme activation of the "anti-binding" mechanism controlling temporal binding at high frequencies. It is suggested that when fast activity is abnormally intensified, "over-binding" with global synchrony of gamma rhythms can occur in the neural networks. It may lead to inadequate synaptic modifications. To prevent this process, epileptiform discharge develops as a protective mechanism suppressing fast activity. This proposal has implications for our understanding of temporal binding in the brain and how its excessive activation may precipitate the development of pathological states.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Acute and continuation treatment of major depressive disorder

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.