Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy

Sackeïm, Harold A.; Prudic, Joan; Nobler, Mitchell S.; Fitzsimons, Linda; Lisanby, Sarah H.; Payne, Nicola; Berman, R.; Brakemeier, Eva‐Lotta; Perera, Tarique D.; Devanand, D. P.

doi:10.1016/j.brs.2008.03.001

Cited by 465 publications

(419 citation statements)

References 27 publications

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“…Therefore, while in our study the current amplitude was more than fivefold lower, there was no apparent reduction in the total charge compared with studies with 800 mA. This observation is corroborated by clinical studies of ultrabrief (0.3 ms) RUL ECT, where the ST charge for 800 mA current (22 ± 8 mC; Sackeim et al, 2008) was similar to that for 500 mA current (21.6 ± 4.8 mC; Rosa et al, 2011). In fact, for some stimulus parameter ranges, the total charge may increase with decreasing current amplitude (Swartz et al, 2012).…”

Section: Stimulus Intensitysupporting

confidence: 81%

Individualized Low-Amplitude Seizure Therapy: Minimizing Current for Electroconvulsive Therapy and Magnetic Seizure Therapy

Peterchev

Krystal

Rosa³

et al. 2015

Neuropsychopharmacol

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Electroconvulsive therapy (ECT) at conventional current amplitudes (800-900 mA) is highly effective but carries the risk of cognitive side effects. Lowering and individualizing the current amplitude may reduce side effects by virtue of a less intense and more focal electric field exposure in the brain, but this aspect of ECT dosing is largely unexplored. Magnetic seizure therapy (MST) induces a weaker and more focal electric field than ECT; however, the pulse amplitude is not individualized and the minimum amplitude required to induce a seizure is unknown. We titrated the amplitude of long stimulus trains (500 pulses) as a means of determining the minimum current amplitude required to induce a seizure with ECT (bilateral, right unilateral, bifrontal, and frontomedial electrode placements) and MST (round coil on vertex) in nonhuman primates. Furthermore, we investigated a novel method of predicting this amplitude-titrated seizure threshold (ST) by a non-convulsive measurement of motor threshold (MT) using single pulses delivered through the ECT electrodes or MST coil. Average STs were substantially lower than conventional pulse amplitudes (112-174 mA for ECT and 37.4% of maximum device amplitude for MST). ST was more variable in ECT than in MST. MT explained 63% of the ST variance and is hence the strongest known predictor of ST. These results indicate that seizures can be induced with less intense electric fields than conventional ECT that may be safer; efficacy and side effects should be evaluated in clinical studies. MT measurement could be a faster and safer alternative to empirical ST titration for ECT and MST.

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Section: Stimulus Intensitysupporting

confidence: 81%

Individualized Low-Amplitude Seizure Therapy: Minimizing Current for Electroconvulsive Therapy and Magnetic Seizure Therapy

Peterchev

Krystal

Rosa³

et al. 2015

Neuropsychopharmacol

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“…A potential benefit of UBP ECS -and UBP ECT for treating depression -is a reduction in the cognitive side effects associated with ECS treatment (Sackeim et al, 2008). In the present study there was a non-significant trend for similar decreases in performance in both the UBP and BP groups compared to the sham control group on hippocampal-dependant reference memory in the water plus maze probe trial.…”

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confidence: 54%

“…0.25 -0.3 milliseconds) pulse stimulation as this is more physiological, reducing stimulation of neurones that are already depolarising or in the refractory period (Sackeim, 2004). The first randomised trial reported a high remission rate (77%) and few cognitive deficits following high-dose right unilateral ultrabrief pulse ECT compared to brief pulse ECT (Sackeim et al, 2008). However, this high remission rate has so far not been replicated in other randomised (6-44%; (Quante et al, 2011;Sienaert et al, 2009)) and non-randomised studies (13-42%; (Loo et al, 2007;Loo et al, 2008;Niemantsverdriet et al, 2011)).…”

Section: Introductionmentioning

confidence: 99%

A comparison of brief pulse and ultrabrief pulse electroconvulsive stimulation on rodent brain and behaviour

O’Donovan

Kennedy

Guinan

et al. 2012

Progress in Neuro-Psychopharmacology and Biological Psychiatry

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Brief pulse electroconvulsive therapy (BP ECT; pulse width 0.5-1.5 msec) is a very effective treatment for severe depression but is associated with cognitive side-effects. It has been proposed that ultrabrief pulse (UBP; pulse width 0.25-0.30 msec) ECT may be as effective as BP ECT but have less cognitive effects because it is a more physiological form of neuronal stimulation. To investigate this further, we treated normal rats with a 10 session course of either BP (0.5 msec), UBP (0.3 msec), or sham electroconvulsive stimulation (ECS) and measured antidepressant-related changes in dentate gyrus cell proliferation and hippocampal BDNF protein levels as well as hippocampal-dependant spatial reference memory using the water plus maze and immobility time on the forced swim test. Both BP and UBP ECS induced very similar types of motor seizures. However, BP ECS but not UBP ECS treatment led to a significant, near 3-fold, increase in cell proliferation (p=0.026) and BDNF levels (p=0.01). In the forced swim test, only BP ECS treated animals had a significantly lower immobility time (p=0.046). There was a trend for similarly reduced hippocampal-dependent memory function in both BP and UBP groups but overall there was not a significant difference between treatment and control animals when tested 10 days after completing allocated treatment. These findings show that, even though both forms of ECS elicited similar motor seizures, UBP ECS was less efficient than BP ECS in inducing antidepressant-related molecular, cellular and behavioural changes.

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“…High-dose is more effective than low-dose ECT but more adversely affects memory (2,7). However, efficacy trials (8)(9)(10)(11)(12)(13) have demonstrated that unilateral ECT can be as effective as bitemporal ECT if delivered in high doses at multiples (e.g., 53-83) of seizure threshold, the minimum charge required to induce the generalized seizure needed for therapeutic effect.…”

mentioning

confidence: 99%

Bitemporal Versus High-Dose Unilateral Twice-Weekly Electroconvulsive Therapy for Depression (EFFECT-Dep): A Pragmatic, Randomized, Non-Inferiority Trial

Semkovska¹,

Landau²,

Dunne³

et al. 2016

AJP

156

118

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Objective: ECT is the most effective treatment for severe depression. Previous efficacy studies, using thrice-weekly brief-pulse ECT, reported that high-dose (63 seizure threshold) right unilateral ECT is similar to bitemporal ECT but may have fewer cognitive side effects. The authors aimed to assess the effectiveness and cognitive side effects of twice-weekly moderate-dose (1.53 seizure threshold) bitemporal ECT with high-dose unilateral ECT in real-world practice.Method: This was a pragmatic, patient-and rater-blinded, noninferiority trial of patients with major depression (N=138; 63% female; age=56.7 years [SD=14.8]) in a national ECT service with a 6-month follow-up. Participants were independently randomly assigned to bitemporal or highdose unilateral ECT. The primary outcome was change in the 24-item Hamilton Depression Rating Scale (HAM-D) score after the ECT course; the prespecified noninferiority margin was 4.0 points. Secondary outcomes included response and remission rates, relapse status after 6 months, and cognition.Results: Of the eligible patients, 69 were assigned to bitemporal ECT and 69 to unilateral ECT. High-dose unilateral ECT was noninferior to bitemporal ECT regarding the 24-item HAM-D scores after the ECT course (mean difference=1.08 points in favor of unilateral ECT [95% CI=21.67 to 3.84]). There were no significant differences for response and remission or 6-month relapse status. Recovery of orientation was quicker following unilateral ECT (median=19.1 minutes versus 26.4 minutes). Bitemporal ECT was associated with a lower percent recall of autobiographical information (odds ratio=0.66) that persisted for 6 months.Conclusions: Twice-weekly high-dose unilateral ECT is not inferior to bitemporal ECT for depression and may be preferable because of its better cognitive side-effect profile.

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Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy

Abstract: The use of an ultrabrief stimulus markedly reduces adverse cognitive effects, and when coupled with markedly suprathreshold right unilateral ECT, also preserves efficacy. (ClinicalTrials.gov number, NCT00487500.).

Cited by 465 publications

References 27 publications

Individualized Low-Amplitude Seizure Therapy: Minimizing Current for Electroconvulsive Therapy and Magnetic Seizure Therapy

Individualized Low-Amplitude Seizure Therapy: Minimizing Current for Electroconvulsive Therapy and Magnetic Seizure Therapy

A comparison of brief pulse and ultrabrief pulse electroconvulsive stimulation on rodent brain and behaviour

Bitemporal Versus High-Dose Unilateral Twice-Weekly Electroconvulsive Therapy for Depression (EFFECT-Dep): A Pragmatic, Randomized, Non-Inferiority Trial

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