ECT electroshock side effects electroconvulsive therapy

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Major enhancements to Electroconvulsive therapy



The major recent enhancements to ECT technique are:

  • Right Unilateral electrode placement. The cognitive side-effects of ECT such as retrograde and anterograde amnesia are significantly less compared to Bilateral electrode placement.
  • Brief pulse stimulus currents. The characteristics of the electrical stimulus affect the effectiveness and cognitive outcomes of the seizure. Sine wave stimuli have been replaced with rectangular pulses on modern ECT devices, leading to a substantial decrease in cognitive effects
  • Improved an­esthesia techniques makes it possible to regulate the cardiac output during ECT when necessary
  • The “dose titra­tion” technique to individualize treatment stimulus dosing
  • The discovery of the dose-response relationship between electrical stimulus dosing and antidepressant outcome with RUL electrode placement
  • Pulse width. Several studies conclude that right unilateral (RUL) electroconvulsive therapy (ECT) given with ultrabrief pulse-width stimulus packages causes less cognitive impairment than other techniques

Contemporary ECT devices can be set to deliver pulse-widths between 0.25 and 2.0 milliseconds. Stimuli between 0.5 and 2.0 milliseconds are called “brief,” and those less than 0.5 millisecond are called “ultra­brief.”

A recent study from Sackeim and colleagues was published about ultrabrief puls width and efficcay and cognitiev side-effects. Those participating in this trial were assessed for depressive symptoms and cognition at baseline, during and after the acute course of ECT, and at 2 and 6 month time points. Responders were monitored for 1 year. Reported re­mission rates were 73% for ultrabrief RUL, 65% for brief pulse BL, 59% for brief pulse RUL, and 35% for ultrabrief BL. Ultrabrief pulse RUL produced less severe cognitive effects than the other 3 treatment groups, both acutely and long-term, on multiple measures in several cognitive domains, including subjective assessment of memory function. Relapse in the year following acute ECT was unrelated to treatment group. These authors concluded, “the use of an ultrabrief stimulus coupled with high-dosage RUL stimulation is a strategy that appears to retain the therapeutic properties of ECT, although substantially reducing its potential for adverse cognitive side effects.”

The big problem is that ultrabrief bilateral treatment is less efficacious in this trial than Right unilateral electrode placement. Normally bilateral ECT is the most efficacious form of ECT. Is this a real difference or is this another strange finding from the Columbia University Group comparable to their results with medication resistant depressed patients. According to their research patients with “medication resistance” as defined by arbitrary (ATHF) criteria were less responsive to ECT. Other researchers couldn’t find any influence of medication resistance on efficacy of subsequent ECT. It seems that medication resistance is irrelevant in the decision for a trial of ECT in patients with severe depressive illness, whether psychotic or non-psychotic.

Does pulse width influence efficacy of bilateral ECT? Opinion from another expert, Charles H Kellner:

Fortunately, the nature of ECT is such that if, after several RUL treatments with ultrabrief pulse stimuli, the patient is not responding adequately, the treatment technique can be switched, either to a different wave­form or electrode placement, or both.

We did a retrospective study comparing bilateral ultrabrief pulse width compared to brief pulse width for depressive disorder. We couldn’t find a significant difference. Is to be continued.

ResearchBlogging.org
SACKEIM, H., PRUDIC, J., NOBLER, M., FITZSIMONS, L., LISANBY, S., PAYNE, N., BERMAN, R., BRAKEMEIER, E., PERERA, T., & DEVANAND, D. (2008). Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy Brain Stimulation, 1 (2), 71-83 DOI: 10.1016/j.brs.2008.03.001

 

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ECT and Pregnancy

pregnancy ect

The last systematic review of this topic was in 1994. According to this recent review ECT does seem to be effective for treating mental illness during pregnancy and the risks of adverse events are low. It should be considered in pregnant women with severe mental illness such as psychotic symptoms, catatonia or strong suicidal urges.

Why is this important?

  • The most common mental illness during pregnancy is major depressive disorder. It is estimated that 9% of pregnant patients suffer from major depressive disorder
  • Untreated depression is linked to poor maternal and neonatal outcomes including poor weight gain during pregnancy, higher risk of alcohol and/or drug abuse, preterm birth, lower birth weight, preeclampsy, and hindered mother infant bonding
  • Elevated risk of suicide
  • ECT is efficacious for major depressive disorder and other severe mental disorders
  • Medications carry a potential risk for the fetus especially in the first trimester.

How was this study done?

English-language and English-language translated articles published since 1941 that included data on ECT in pregnancy were located in bibliographic databases, online sites, journal issues, and secondary sources, such as journal articles and book chapters. PubMed and PsycINFO were searched using the terms “ECT,” “electroshock,” “electroconvulsive” or “electroconvulsive shock,” and “pregnancy.”

The search yielded 57 articles that met the inclusion criteria and dated from 1942-2007. The total number of cases described was 339.

Results

  • The mean number of treatments was 10.8 (range 1-35). Gestational age was reported in 71 cases. Fifteen patients received ECT in the first trimester, 37 received ECT in the second trimester, and 19 in the third trimester.
  • Efficacy data were available on 68 of 339 cases. Of these 37 were diagnosed with either MDD or “depression” (with or without psychosis) and the rate of at least partial response was 84%. Twenty-one pregnant women were treated for schizophrenia or schizophreniform disorder and the rate of at least partial remission was 61%.
  • There were 25 of the 339 cases in which fetal or neonatal abnormalities were reported. death (n=11), transient fetal bradycardia and or decelerations (n=8), peritonitis (n=1), club foot (n=1), prematurity (n=1), congenital pulmonary cysts (n=2), congenital blindness (n=1), great vessel transposition (n=2), aorta coarctation (n=1), cortical infarcts (n=1), anencephaly (n=1), VATER syndrome (n=1), and mental retardation (n=1).
  • Of the 11 reported fetal or neonatal deaths, only one was believed to be the direct result of ECT, death followed an episode of status epilepticus in the mother secondary to ECT. The others were believed to be unrelated to ECT
  • Among the nonfatal complications only 8 cases of abnormal transient fetal arrhytmias and one case of multiple interhemispheric infarctions were believed to be related to ECT.
  • There were 18 of 339 maternal cases described with complications likely related to ECT.
  • Of the 8 fetal and 18 maternal cases describing complications likely related to ECT includes 4 cases that each have both a neonatal and maternal complication.

Conclusion (with my 2 cents added)
ECT is an option with severe mental health disorder during pregnancy. Some precautionary measures should be taken with ECT durnig pregnancy:

  • Positioning a woman during the latter stages of pregnancy to minimize aortocaval compression by elevating the right hip and displacing the uterus will also improve placental perfusion and minimize the risk of hypoxia in the fetus.
  • From the third trimester intubation is always necessary. The authors don’t mention this in their article but it should have
  • Tocodynamometry during ECT administration can be used for monitoring uterine activity. In the event of uterine contractions, tocolysis with alfa-2-adrenergic agonists like ritodrine can be administered.
  • Given the potential for general anesthesia to sedate the fetus, obstetric fetal monitoring is necessary during ECT. We don’t always do this, it depends on the trimester and growth of the fetus. We do it at least once every month during a ECT session.

no randomized, controlled trial has yet been conducted evaluating ECT efficacy for treating major mental illness during pregnancy.

Another limitation of this review is reporting bias. Adverse or unusual outcomes post treatment with ECT are much more likely to be reported than normal or uneventful outcomes. This review did not focus on long term outcome.

Obstretic fetal monitoring is one suggestion of debate, how often should this be done, every treatment, all trimesters? Nobody knows. Any idea anyone? Let me know your experiences with ECT during pregnancy in the comments.

Related post on this blog: Electroconvulsive therapy and pregnancy, a case report
Why pregnant women don’t tip over
ResearchBlogging.org
E. L. Anderson, I. M. Reti (2008). ECT in Pregnancy: A Review of the Literature From 1941 to 2007 Psychosomatic Medicine DOI: 10.1097/PSY.0b013e318190d7ca

 

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Electroconvulsive therapy, evidence and challenges


A commentary in the JAMA by Prof Max Fink. In this commentayr he sumarizes the most important recent topics in ECT.
1. Remission for depressive illness with ECT: 55%-86%, these results compare favorably to the response rates in the STAR*D trial.
2. Relapse prevention after ECT, nortriptyline with lithium is first choice, continuation ECT for patients who relapse despite this treatment and for those who may not tolerate medication.
3. ECT is a primary treatment for psychotic depression.
4. ECT reduces the acute risk for suicide.
5. Medication resistance does not bare relation to treatment efficacy with ECT.
6. He still favours bilateral electrode placement.
7. Important side effects are anterograde-, retrograde amnesia.
8. Vagus Nerve Stimulation and Deep Brain Stimulation are not comparable in efficacy to ECT.

This is in short his few about the recent achievements in ECT treatment and it’s research. His preference for bilateral ECT is a topic for debate. Unilateral electrode placement is technically more complex but comparable in efficacy when done the right way. That is with supratreshold stimulus dosage after stimulus titration during the first session. Research with side effects should be done for the long term and focussed on individual differences