Out on PubMed is this study from Harold Sackeim and collaborators:
The Benefits and Costs of Changing Treatment Technique in Electroconvulsive Therapy Due to Insufficient Improvement of a Major Depressive Episode.
The Benefits and Costs of Changing Treatment Technique in Electroconvulsive Therapy Due to Insufficient Improvement of a Major Depressive Episode.
The abstract is at the above link and copied here:Background: Electroconvulsive therapy (ECT) technique is often changed after insufficient improvement, yet there has been little research on switching strategies. Objective: To document clinical outcome in ECT nonresponders who were received a second course using high dose, brief pulse, bifrontotemporal (HD BP BL) ECT, and compare relapse rates and cognitive effects relative to patients who received only one ECT course and as a function of the type of ECT first received. Methods: Patients were classified as receiving Weak, Strong, or HD BP BL ECT during three randomized trials at Columbia University. Nonresponders received HD BP BL ECT. In a separate multi-site trial, Optimization of ECT, patients were randomized to right unilateral or BL ECT and nonresponders also received further treatment with HD BP BL ECT. Results: Remission rates with a second course of HD BP BL ECT were high in ECT nonresponders, approximately 60% and 40% in the Columbia University and Optimization of ECT studies, respectively. Clinical outcome was independent of the type of ECT first received. A second course with HD BP BL ECT resulted in greater retrograde amnesia immediately, two months, and six months following ECT. Conclusions: In the largest samples of ECT nonresponders studied to date, a second course of ECT had marked antidepressant effects. Since the therapeutic effects were independent of the technique first administered, it is possible that many patients may benefit simply from longer courses of ECT. Randomized trials are needed to determine whether, when, and how to change treatment technique in ECT.
This is a new look at old data. The idea that it does not matter whether an acute course of ECT is initiated with weak, strong or very strong ECT seems questionable. Overall, the conclusion here is similar to that of van Duist et al. (see below) that more ECT is often the way to achieve remission in slow-to-respond patients. I wholeheartedly agree that randomized trials are needed to guide practice protocols into how to strengthen ECT technique for patients who show inadequate improvement during their acute course of ECT.
See also blog post of 6/24/2020 re :
J Affect Disord. 2020 Jul 1;272:501-507. doi: 10.1016/j.jad.2020.03.134. Epub 2020 Apr 29.
PMID: 32553394
The below comment is from Max Fink:
ReplyDeleteTime to limit RUL ECT?
The awareness that RUL ECT is less effective than BT ECT has grown steadily since the first trial comparisons in 1950s, repeated in 1970s, and again in 1990s. The trials led by psychologist's preoccupation with the immediate impairments of memory and orientation occasioned by induced seizures should end. Weakening the stimulus minimizes immediate cognitive effects at the price of lesser efficacy, longer courses of treatment, and as reported here, impaired long term benefits. A similar finding by a Dutch group was recently reported in this blog (June 24, 2020)
BT ECT is optimal not only in depression but surely in catatonia, NMS, delirious mania, self injurious behaviors in autism, and limbic encephalitis. Treating elderly depressed with cognitive impairment occasionally justifies RUL to minimize immediate cognitive effects, but the risk of overall poor outcome limits such decisions.
After decades of trials, inducing poorly efficient seizures by less efficient currents are to be questioned by ethical considerations.
Max Fink
Ottosson J-O, Fink M. Ethics in Electroconvulsive Therapy. NY: Bruner-Routledge, 2004.