Dunne RA, McLoughlin DM. Systematic review and meta-analysis of bifrontal electroconvulsive therapy versus bilateral and unilateral electroconvulsive therapy in depression. World J Biol Psychiatry 13: 248-258
Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, Dublin, Ireland. The World Journal of Biological Psychiatry
(Impact Factor: 4.18).
11/2011; 13(4):248-58. DOI: 10.3109/15622975.2011.615863
Our aim was to perform a meta-analysis of randomized controlled trials comparing efficacy and side effects of bifrontal (BF) ECT to bitemporal (BT) or unilateral (RUL) ECT in depression.
We performed a systematic review of randomized controlled trials comparing BF ECT with RUL or BT ECT in depression. Eight trials (n=617) reported some cognitive outcome. Efficacy was measured by reduction in Hamilton Depression Rating Scale score. Cognitive outcomes were limited to Mini-Mental State Examination (MMSE) in seven studies, with two studies measuring each of: Complex-figure delayed recall, Trail-making tests and verbal learning.
Efficacy was equal between BF and BT ECT (Hedges's g=0.102, P=0.345, confidence interval (CI): -0.110, 0.313) and BF and RUL ECT (standardized mean difference=-0.12, P=0.365, CI: -0.378, 0.139). Post-treatment MMSE score decline was less for BF than BT ECT (g=0.89, CI: 0.054, 1.724) but not RUL ECT. RUL ECT impaired Complex figure recall more than BF ECT (g=0.76, CI :0.487, 1.035), but BF ECT impaired word recall more than RUL ECT (g=-1.45, CI: -2.75, -0.15).
Bifrontal ECT is not more effective than BT or RUL ECT but may have modest short-term benefits for specific memory domains. BF ECT has potential advantages, but given longer experience with BT and RUL, bifrontal ECT requires better characterization.
Available from: Andrea T White
- "Electroconvulsive therapy (ECT) is widely acknowledged to be the most effective option, achieving remission in 55–90% of the cases, even among patients who were previously refractory  . Despite its safety and efficacy , many millions of patients with refractory DD elect not to receive ECT due, in large part, to misperceptions about this treatment being painful or traumatic or to concerns regarding associated adverse cognitive effects, most of which are, however, temporary  . This has encouraged efforts to find alternative therapies "
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ABSTRACT: Objective. To evaluate leukocyte gene expression for 9 selected genes (mRNAs) as biological markers in patients with medication refractory depression before and after treatment with ECT or isoflurane anesthesia (ISO). Methods. In a substudy of a nonrandomized open-label trial comparing effects of ECT to ISO therapy, blood samples were obtained before and after treatment from 22 patients with refractory depression, and leukocyte mRNA was assessed by quantitative PCR. Patients’ mRNAs were also compared to 17 healthy controls. Results. Relative to controls, patients before treatment showed significantly higher IL10 and DBI and lower ADRA2A and ASIC3 mRNA (
). Both ECT and ISO induced significant decreases after treatment in 4 genes: IL10, NR3C1, DRD4, and Sult1A1. After treatment, patients’ DBI, ASIC3, and ADRA2A mRNA remained dysregulated. Conclusion. Significant differences from controls and/or significant changes after ECT or ISO treatment were observed for 7 of the 9 mRNAs studied. Decreased expression of 4 genes after effective treatment with either ECT or ISO suggests possible overlap of underlying mechanisms. Three genes showing dysregulation before and after treatment may be trait-like biomarkers of medication refractory depression. Gene expression for these patients has the potential to facilitate diagnosis, clarify pathophysiology, and identify potential biomarkers for treatment effects.
Available from: Andrew Harkin
- "Electrode placement can also impact on the severity of the side-effects experienced following treatment. There is little difference between bitemporal and bifrontal electrode placement (Dunne and McLoughlin, 2012) while right unilateral electrode placement results in fewer cognitive side-effects but, unless higher stimulus doses are used, is not as effective as bitemporal ECT (Sackeim et al., 1993; Semkovska et al., 2011). Another mechanism to minimise the side-effects of ECT is to reduce the pulse width at which ECT is delivered from a brief pulse (BP) width of 0.5–1.5 ms to an ultrabrief pulse (UBP) width of 0.3 ms that is closer to the minimum pulse width required for neuronal depolarisation (0.1–0.2 ms) (Ranck, 1975). "
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ABSTRACT: Brief pulse electroconvulsive therapy (BP ECT; pulse width 0.5-1.5 ms) is the most effective treatment available for severe depression. However, its use is associated with side-effects. The stimulus in ultrabrief pulse ECT (UBP ECT; pulse width 0.25-0.3 ms) is more physiological and has been reported to be associated with less cognitive side-effects, but its antidepressant effectiveness is not yet well established. Using electroconvulsive stimulation (ECS), the animal model of ECT, we previously reported UBP ECS to be significantly less effective than well-established BP ECS in eliciting behavioural, molecular and cellular antidepressant-related effects in naïve rats. We have now compared the effects of BP and UBP ECS in an animal model of depression related to exogenous supplementation with the stress-induced glucocorticoid hormone, corticosterone. Corticosterone administration resulted in an increase in immobility time in the forced swim test (FST) (p < 0.01) and decreases in the expression of brain-derived neurotrophic factor (BDNF) (p < 0.05) and glial fibrillary acidic protein (GFAP) (p < 0.001) in the hippocampus and frontal cortex. There was no significant difference in the duration or type of seizure induced by BP (0.5 ms) or UBP (0.3 ms) ECS. UBP ECS proved to be as effective as BP ECS at inducing a behavioural antidepressant response in the FST with a significant decrease (p < 0.001) in immobility seen following administration of ECS. Both forms of ECS also induced significant increases in BDNF protein (p < 0.01) expression in the hippocampus. BP ECS (p < 0.05) but not UBP ECS induced a significant increase in GFAP levels in the hippocampus and frontal cortex. Overall, UBP ECS effectively induced antidepressant-related behavioural and molecular responses in the corticosterone supplementation model, providing the first preclinical data on the potential role of this form of ECS to treat a depression phenotype related to elevated corticosterone.
Available from: Erik Kolshus
- "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.
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