Bitemporal <i>v</i>. high-dose right unilateral electroconvulsive therapy for depression: a systematic review and meta-analysis of randomized controlled trials

Kolshus, Erik; Jelovac, Ana; McLoughlin, Declan M.

doi:10.1017/s0033291716002737

Cited by 112 publications

(99 citation statements)

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“…Cognitive impairment and effectiveness of treatment are both related to the stimulus dose, especially for right unilateral ECT,2, 3 and there is a clinical trade-off between the two effects; a meta-analysis 12 found that high-dose right unilateral ECT was as effective as moderate-dose bitemporal ECT, with a similar cognitive effect profile for anterograde memory and verbal fluency; however, right unilateral ECT might have benefits for retrograde autobiographical memory and reorientation time after seizure. Ultra-brief pulse right unilateral ECT (pulse width 0·3 ms) was associated with less cognitive impairment but was also less effective than brief pulse right unilateral ECT (pulse width 1·0–1·5 ms) 13 .…”

Section: Introductionmentioning

confidence: 99%

Ketamine augmentation of electroconvulsive therapy to improve neuropsychological and clinical outcomes in depression (Ketamine-ECT): a multicentre, double-blind, randomised, parallel-group, superiority trial

Anderson

Blamire

Branton

et al. 2017

The Lancet Psychiatry

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SummaryBackgroundThe use of electroconvulsive therapy (ECT) is limited by concerns about its cognitive adverse effects. Preliminary evidence suggests that administering the glutamate antagonist ketamine with ECT might alleviate cognitive adverse effects and accelerate symptomatic improvement; we tested this in a randomised trial of low-dose ketamine.MethodsIn this multicentre, randomised, parallel-group study in 11 ECT suites serving inpatient and outpatient care settings in seven National Health Service trusts in the North of England, we recruited severely depressed patients, who were diagnosed as having unipolar or bipolar depressive episodes defined as moderate or severe by DSM-IV criteria, aged at least 18 years, and were able and willing to provide written consent to participate in the study. Patients were randomly assigned (1:1) to ketamine (0·5 mg/kg intravenous bolus) or saline adjunctive to the anaesthetic for the duration of their ECT course. Patients and assessment and ECT treatment teams were masked to treatment allocation, although anaesthetists administering the study medication were not. We analysed the primary outcome, Hopkins Verbal Learning Test-Revised delayed verbal recall (HVLT-R-DR) after four ECT treatments, using a Gaussian repeated measures model in all patients receiving the first ECT treatment. In the same population, safety was assessed by adverse effect monitoring. This trial was registered with International Standard Randomised Controlled Trial Number, number ISRCTN14689382.FindingsBetween early December, 2012, and mid-June, 2015, 628 patients were screened for eligibility, of whom 79 were randomly assigned to treatment (40 in the ketamine group vs 39 in the saline group). Ketamine (mean 5·17, SD 2·92), when compared with saline (5·54, 3·42), had no benefit on the primary outcome (HVLT-R-DR; difference in means −0·43 [95% CI −1·73 to 0·87]). 15 (45%) of 33 ketamine-treated patients compared with 10 (27%) of 37 patients receiving saline experienced at least one adverse event which included two (6%) of 33 patients who had ketamine-attributable transient psychological effects. Psychiatric adverse events were the most common in both groups (six [27%] of 22 adverse events in the ketamine group vs seven [54%] of 13 in the saline group).InterpretationNo evidence of benefit for ketamine was found although the sample size used was small; however, the results excluded greater than a small to moderate benefit with 95% confidence. The results do not support the use of adjunctive low-dose ketamine in routine ECT treatment.FundingNational Institute for Health Research (NIHR) Efficacy and Mechanism Evaluation (EME) programme, an MRC and NIHR partnership.

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Section: Introductionmentioning

confidence: 99%

Ketamine augmentation of electroconvulsive therapy to improve neuropsychological and clinical outcomes in depression (Ketamine-ECT): a multicentre, double-blind, randomised, parallel-group, superiority trial

Anderson

Blamire

Branton

et al. 2017

The Lancet Psychiatry

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“…82 In the past, there was controversy as to the comparative efficacy of RUL vs. bitemporal ECT, the latter being considered more effective. However, recent meta-analyses have found that high-dose RUL and bitemporal ECT are equally effective, 17,85 and considered that previous RUL ECT trials that used lower doses (e.g., less than six times the seizure threshold) might have underestimated its treatment effects. More recently, bifrontal ECT has been introduced as a form of ECT with efficacy comparable to that of bitemporal ECT, but fewer side effects.…”

Section: Convulsive Modalitiesmentioning

confidence: 99%

“…For convulsive therapies, there might be a trade-off between using higher doses to produce greater clinical benefits but with additional side effects. 85 More recently, computational models have been used to quantify electric fields (EFs) in brain regions of interest (ROIs). In fact, there are freely available software packages that perform electric field simulations using high-quality MRI images (templates or individualized) via a series of steps: 1) automated tissue segmentation of structural MRI; 2) meshing of the different tissue compartments to form a 3D model of the head and brain; 3) processing DTI data to extract white-matter anisotropic conductivity values; 4) incorporating electrodes and the TMS coil on the head model; 5) assigning appropriate electrical properties for the tissues and electrode/coil; 6) solving for the electric field and current density, via numerical methods such as finite element or boundary element methods; and 7) exporting, visualizing, and/or transforming electric field distribution to standard space for group analysis.…”

Section: Convulsive Modalitiesmentioning

confidence: 99%

Precision non-implantable neuromodulation therapies: a perspective for the depressed brain

Borrione

Bellini

Razza

et al. 2020

Braz. J. Psychiatry

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Current first-line treatments for major depressive disorder (MDD) include pharmacotherapy and cognitive-behavioral therapy. However, one-third of depressed patients do not achieve remission after multiple medication trials, and psychotherapy can be costly and time-consuming. Although nonimplantable neuromodulation (NIN) techniques such as transcranial magnetic stimulation, transcranial direct current stimulation, electroconvulsive therapy, and magnetic seizure therapy are gaining momentum for treating MDD, the efficacy of non-convulsive techniques is still modest, whereas use of convulsive modalities is limited by their cognitive side effects. In this context, we propose that NIN techniques could benefit from a precision-oriented approach. In this review, we discuss the challenges and opportunities in implementing such a framework, focusing on enhancing NIN effects via a combination of individualized cognitive interventions, using closed-loop approaches, identifying multimodal biomarkers, using computer electric field modeling to guide targeting and quantify dosage, and using machine learning algorithms to integrate data collected at multiple biological levels and identify clinical responders. Though promising, this framework is currently limited, as previous studies have employed small samples and did not sufficiently explore pathophysiological mechanisms Brazilian Psychiatric Association 0 0 0 0 0 0 0 0 -0 0 0 2 -7 3 1 6 -1 1 8 5 associated with NIN response and side effects. Moreover, cost-effectiveness analyses have not been performed. Nevertheless, further advancements in clinical trials of NIN could shift the field toward a more ''precision-oriented'' practice. DisclosureZ-DD is listed as inventor on patents/patent applications related to brain stimulation technology, assigned to Columbia University and NEVA Electromagnetics, not licensed, and with no remuneration. Although he is an employee of the U.S. government, the views expressed Braz J Psychiatry. 2020;00 (00) Precision NIN for depression

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“…Brief pulse (1.0 ms), high dose unilateral ECT is as effective as the original bitemporal placement of electrodes, with fewer cognitive side effects, including on autobiographical memory 28. These effects are further reduced by using ultrabrief pulse (0.3 ms) ECT, though it has slightly lower remission rates 29…”

Section: No— Sameer Jauhar and Declan M Mcloughlinmentioning

confidence: 99%

Should we stop using electroconvulsive therapy?

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Cunliffe²,

Jauhar

et al. 2019

BMJ

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Bitemporal v. high-dose right unilateral electroconvulsive therapy for depression: a systematic review and meta-analysis of randomized controlled trials

Abstract: High-dose unilateral ECT does not differ from moderate-dose bitemporal ECT in antidepressant efficacy but has some cognitive advantages.

Cited by 112 publications

References 56 publications

Ketamine augmentation of electroconvulsive therapy to improve neuropsychological and clinical outcomes in depression (Ketamine-ECT): a multicentre, double-blind, randomised, parallel-group, superiority trial

Ketamine augmentation of electroconvulsive therapy to improve neuropsychological and clinical outcomes in depression (Ketamine-ECT): a multicentre, double-blind, randomised, parallel-group, superiority trial

Precision non-implantable neuromodulation therapies: a perspective for the depressed brain

Should we stop using electroconvulsive therapy?

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