Article

ECT efficacy and treatment course: a systematic review and meta-analysis of twice vs thrice weekly schedules. J Affect Disord

Queensland Centre for Mental Health Research, School of Population Health, University of Queensland, Australia.
Journal of Affective Disorders (Impact Factor: 3.38). 04/2011; 138(1-2):1-8. DOI: 10.1016/j.jad.2011.03.039
Source: PubMed

ABSTRACT

Electroconvulsive therapy (ECT) guidelines, across various regulatory bodies, lack consensus as to the optimal frequency of treatment for individual patients. Some authors postulate that twice weekly ECT may have a similar efficacy to thrice weekly, and may have a lower risk of adverse cognitive outcomes. We did a systematic review and a meta-analysis to assess the strength of associations between ECT frequency and depression scores, duration of treatment, number of ECTs, and remission rates.
We searched on Medline, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (to December 2009), and searched reports to identify comparative studies of frequency of ECT. We did both random-effects (RE) and quality effect (QE) meta-analyses to determine the risk of various outcomes associated with lesser frequency as compared to the thrice weekly frequency.
We analysed 8 datasets (7 articles), including 214 subjects. Twice-weekly frequency of ECT was associated with a similar change in depression score (QE model SMD -0.11 [-0.55-0.33] and RE model SMD -0.17 [-0.77-0.43]) as compared to thrice weekly ECT. The number of real ECT's trended towards fewer in the twice weekly group. There was a statistically significant longer duration of treatment with a twice weekly protocol (QE model 6.48 days [4.99-7.97] and RE model 4.78 days [0.74-8.82]). There was a statistically significant greater efficacy for thrice weekly ECT compared to once weekly ECT (QE model SMD 1.25 [-0.62-1.9] and RE model SMD 1.31 [0.6-2.02]).
Twice weekly ECT is associated with similar efficacy to thrice weekly ECT, may require fewer treatments and may be associated with longer treatment duration when compared to thrice weekly. These epidemiological observations support the routine use of twice weekly ECT in acute courses, though choice of frequency should take into account individual patient factors. These observations have implications for resource utilisation e.g. costs of duration of admission vs cost of provision of ECT, as well as issues of access to inpatient beds and anaesthetist time.

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Available from: Fiona J Charlson, Oct 29, 2014
    • "(Petrides et al., 2015) However, this was a predetermined schedule aiming for 20 ECT treatments, and which was not based on randomised comparisons of short versus longer courses of treatment. Taken together, these data suggest, but by no means prove, that a larger number of ECT treatments may be required in order to achieve a response in TRS than is the case in depression (Charlson et al., 2012). 5.2.2. "
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    ABSTRACT: The primary aim of this systematic review and meta-analysis was to assess the proportion of patients with Treatment Resistant Schizophrenia (TRS) that respond to ECT augmentation of clozapine (C + ECT). We searched major electronic databases from 1980 to July 2015. We conducted a random effects meta-analysis reporting the proportion of responders to C + ECT in RCTs and open-label trials. Five clinical trials met our eligibility criteria, allowing us to pool data from 71 people with TRS who underwent C+ ECT across 4 open label trials (n = 32) and 1 RCT (n = 39). The overall pooled proportion of response to C + ECT was 54%, (95% CI: 21.8–83.6%) with some heterogeneity evident (I2 = 69%). With data from retrospective chart reviews, case series and case reports, 192 people treated with C + ECT were included. All studies together demonstrated an overall response to C + ECT of 66% (95% CI: 57.5–74.3%) (83 out of 126 patients responded to C + ECT). The mean number of ECT treatments used to augment clozapine was 11.3. 32% of cases (20 out of 62 patients) with follow up data (range of follow up: 3–468 weeks) relapsed following cessation of ECT. Adverse events were reported in 14% of identified cases (24 out of 166 patients). There is a paucity of controlled studies in the literature, with only one single blinded randomised controlled study located, and the predominance of open label trials used in the meta-analysis is a limitation. The data suggests that ECT may be an effective and safe clozapine augmentation strategy in TRS. A higher number of ECT treatments may be required than is standard for other clinical indications. Further research is needed before ECT can be included in standard TRS treatment algorithms.
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    • "When it comes to frequency of ECT there is no significant difference between once, twice or thrice a week but the response might be faster for thrice a week. The trend suggests that twice a week might be the best compromise for elective cases and thrice a week for urgent cases [28]. The evidence suggests that higher electric dose relative to the individual seizure threshold is needed for unilateral lead placement compared to bilateral lead placement. "

    Full-text · Chapter · Aug 2014
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    • "When it comes to frequency of ECT there is no significant difference between once, twice or thrice a week but the response might be faster for thrice a week. The trend suggests that twice a week might be the best compromise for elective cases and thrice a week for urgent cases [28]. The evidence suggests that higher electric dose relative to the individual seizure threshold is needed for unilateral lead placement compared to bilateral lead placement. "
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    ABSTRACT: After nearly a century of use and despite its many controversies, Electroconvulsive therapy (ECT) continues to be practiced and remains a viable treatment option in modern day psychiatry. Arriving on the scene in the 1930s when limited therapeutic options were available, ECT transformed psychiatry and created hope for the severely mentally ill. Unfortunately, it rapidly was seen as a panacea and was used for a wide variety of psychiatric disorders, many of which did not respond to it. The reputation of ECT suffered due to its inappropriate application and a negative public portrayal of the treatment by the anti-psychiatry movement and in Hollywood movies. The arrival of effective psychotropic medications created an exaggerated hope that ECT and other "invasive" procedures used to treat the severely mentally ill would be eliminated. However, ECT continues to be practiced - it stood the test of time because evidence suggests that there is no other treatment in psychiatry that approaches its efficacy in the management of certain psychiatric illnesses like severe depression. Modern day psychiatry is turning back to ECT when needing a quick response or faced with the history of medication resistance. However, ECT is not always practiced in accordance with available treatment guidelines and many health centers do not even have a policy for the safe and evidence-informed practice of ECT. In this chapter, we summarize the current evidence for the use of ECT in psychiatric illnesses, including benefits and risks, and outline a model of ECT service delivery informed by current published evidence and consensus guidelines.
    Full-text · Chapter · Jan 2014
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