Bifrontal, bitemporal and right unilateral electrode placement in ECT: Randomised trial

Department of Psychiatry, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA.
The British journal of psychiatry: the journal of mental science (Impact Factor: 7.99). 03/2010; 196(3):226-34. DOI: 10.1192/bjp.bp.109.066183
Source: PubMed


Electroconvulsive therapy (ECT) is an effective treatment for major depression. Optimising efficacy and minimising cognitive impairment are goals of ongoing technical refinements.
To compare the efficacy and cognitive effects of a novel electrode placement, bifrontal, with two standard electrode placements, bitemporal and right unilateral in ECT.
This multicentre randomised, double-blind, controlled trial (NCT00069407) was carried out from 2001 to 2006. A total of 230 individuals with major depression, bipolar and unipolar, were randomly assigned to one of three electrode placements during a course of ECT: bifrontal at one and a half times seizure threshold, bitemporal at one and a half times seizure threshold and right unilateral at six times seizure threshold.
All three electrode placements resulted in both clinically and statistically significant antidepressant outcomes. Remission rates were 55% (95% CI 43-66%) with right unilateral, 61% with bifrontal (95% CI 50-71%) and 64% (95% CI 53-75%) with bitemporal. Bitemporal resulted in a more rapid decline in symptom ratings over the early course of treatment. Cognitive data revealed few differences between the electrode placements on a variety of neuropsychological instruments.
Each electrode placement is a very effective antidepressant treatment when given with appropriate electrical dosing. Bitemporal leads to more rapid symptom reduction and should be considered the preferred placement for urgent clinical situations. The cognitive profile of bifrontal is not substantially different from that of bitemporal.

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    • "Proliferation of newborn cells in the rat dentate gyros has also been demonstrated after a single application of ECS (Ito et al., 2010; Madsen et al., 2000). These findings suggest possible beneficial effects of a single application of ECS, which in clinical settings are supported by a number of trials with patients receiving a single session of ECT (Kellner et al., 2010; Thomas and Kellner, 2003). "
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    ABSTRACT: Electroconvulsive therapy (ECT) remains the treatment of choice for patients with severe or drug-resistant depressive disorders, yet the mechanism behind its efficacy remains poorly characterized. In the present study, we used electroconvulsive seizures (ECS), an animal model of ECT, to identify proteins possibly involved in the preventive effect of ECS on stress-induced neuronal atrophy in the hippocampus. Rats were stressed daily using the 21-day 6h daily restraint stress paradigm and subjected to sham seizures, a single ECS on the last day of the restraint period or daily repeated seizures for 10 consecutive days during the end of the restraint period. Consistent with previous findings, dendritic atrophy was observed in the CA3c hippocampal region of chronically stressed rats. In addition, we confirmed our recent findings of increased spine density in the CA1 region following chronic restraint stress. The morphological alterations in the CA3c area were prevented by treatment with ECS. On the molecular level, we showed that the synaptic proteins Homer1 and Spinophilin are targeted by ECS. Repeated ECS blocked stress-induced up-regulation of Spinophilin protein levels and further increased the stress-induced up-regulation of Homer1. Given the roles of Spinophilin in the regulation of AMPA receptors and Homer1 in the regulation of metabotropic glutamate receptors (mGluRs), our data imply the existence of a mechanism where ECS regulate cell excitability by modulating AMPA receptor function and mGluR related calcium homeostasis. These molecular changes could potentially contribute to the mechanism induced by ECS which prevents the stress-induced morphological changes in the CA3c region. Copyright © 2015 Elsevier B.V. and ECNP. All rights reserved.
    European neuropsychopharmacology: the journal of the European College of Neuropsychopharmacology 04/2015; in press. DOI:10.1016/j.euroneuro.2015.04.011 · 4.37 Impact Factor
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    • "Most experimental work over the past 3 decades has focused primarily on optimizing ECT treatment parameters (eg, electrode placement, stimulus dose, and pulse width) to produce the best possible balance between clinical and neuropsychological outcomes. These studies unequivocally show that ECT is a powerful treatment option capable of producing full remission where other treatments have failed (Dunne and McLoughlin, 2012; Eranti et al, 2007; Kellner et al, 2010; Loo et al, 2012; Sackeim et al, 2009). However, given that relapse following ECT is a key clinical problem, we carried out a systematic review of all existing evidence, randomized and observational, to provide an overview of current knowledge on this important question. "
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    ABSTRACT: High rates of early relapse following electroconvulsive therapy (ECT) are typically reported in the literature. Current treatment guidelines offer little information to clinicians on the optimal nature of maintenance therapy following ECT. The aim of this study was to provide a systematic overview of the existing evidence regarding post ECT relapse. A keyword search of electronic databases was performed for studies appearing in the peer-reviewed literature before January 2013 reporting on relapse rates in responders to an acute course of ECT administered for a major depressive episode. Meta-analyses were performed where appropriate. Thirty-two studies with up to two years' duration of follow-up were included. In modern-era studies of continuation pharmacotherapy, 51.1% (95% CI=44.7-57.4%) of patients relapsed by 12 months following successful initial treatment with ECT, with the majority (37.7%, 95% CI=30.7-45.2%) relapsing within the first six months. The six-month relapse rate was similar in patients treated with continuation ECT (37.2%, 95% CI=23.4-53.5%). In randomised controlled trials, antidepressant medication halved the risk of relapse compared to placebo in the first six months (risk ratio=0.49, 95% CI=0.39-0.62, p<0.0001, number needed to treat=3.3). Despite continuation therapy, the risk of relapse within the first year following ECT is substantial, with the period of greatest risk being the first six months. The largest evidence base for efficacy in post ECT relapse prevention exists for tricyclic antidepressants. Published evidence is limited or non-existent for commonly used newer antidepressants or popular augmentation strategies. Maintenance of well-being following successful ECT needs to be improved.Neuropsychopharmacology accepted article preview online, 18 June 2013; doi:10.1038/npp.2013.149.
    Neuropsychopharmacology: official publication of the American College of Neuropsychopharmacology 06/2013; 38(12). DOI:10.1038/npp.2013.149 · 7.05 Impact Factor
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    • "•Right unilateral stimulation [25] "
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    ABSTRACT: Electroconvulsive treatment (ECT) has developed over 70 years to a modern, effective way of lifting depressive moods. Memory loss and visual acuity after electroconvulsive treatment is the only remaining relevant criticism of the treatment modality when considering the overall rate of remission from this treatment compared to all other treatment modalities. A depressive state impedes memory, and memory improves on several qualities of cognition after treatment. However, the comparison of a person's memory ability from the months before depression started to the level after a course of ECT is never performed, for obvious reasons. Some infectious diseases are known to influence memory negatively through effects on the dopamine receptors. More specifically, former toxoplasmosis infection may be a factor. Preliminary data on titres of toxoplasma IgG may indicate a connection to the development of long-standing memory problems after ECT.
    02/2012; 1(4):80-3.
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