Anesthesia-to-Stimulus Timing: New Retrospective Study

Out on PubMed, from investigators in Singapore and Australia, is this study:

Association of Anaesthesia-ECT time interval with ECT clinical outcomes: A retrospective cohort study.

Tan XW, Tor PC, Martin D, Loo C.J Affect Disord. 2021 Feb 19;285:58-62. doi: 10.1016/j.jad.2021.02.038. Online ahead of print.PMID: 33636671

The abstract is copied below:

Aim: To examine the association of the anaesthesia to ECT stimulus TI (anaesthesia-ECT TI) with efficacy and cognitive outcomes after ECT treatment.

Methods: Retrospective cohort study of 690 patients who received ECT from July 2017 till December 2019. Generalized linear regression was utilized to analyse the association of mean anaesthesia-ECT TI (from session 2 to session 6 ECT treatment) with Clinical Global Impression-Severity scale (CGI-S) scores and Montreal Cognitive Assessment (MoCA) score after 6 ECT treatments, and with EEG quality during the treatments (post ictal suppression scores).

Results: The averaged TI was 106.6±20.2 (mean±SD) seconds. There was significant improvement of overall CGI-S score after ECT treatment (3.3±1.0) vs pre-ECT treatment (5.0±0.8, p<0.001) while there was no significant change of MoCA score over the course of 6 ECT (p>0.05). The anaesthesia-ECT TI had no association with post-ECT CGI-S while longer anaesthesia-ECT TI was associated with poorer post-ECT MoCA scores [adjusted β, -0.056; 95% CI (-0.099, -0.013), p=0.011] and better EEG quality score [adjusted β (0.001), 95% CI (0, 0.002), p=0.011].

Conclusion: Longer TI between anaesthesia and ECT stimulus administration resulted in higher seizure quality, suggesting more effective stimulation. This was associated with more cognitive impairment but not higher efficacy. The assessment of outcomes after only 6 ECT limited the ability to fully explore associations between the TI and clinical outcomes. This was a retrospective analysis of clinical data from a real-world treatment setting. A controlled study would provide greater potential to fully explore the association between TI and clinical outcomes.


...and from the text:
This is the first study to examine efficacy and cognitive outcomes of ECT, against the anaesthesia-ECT time interval. Contrary to our hypotheses, we found no evidence that the anaesthesia-ECT TI was related to the efficacy of ECT as measured in change in general disease severity scores after 6 ECT treatments, but a small association between longer anaesthesia-ECT TIs and poorer cognitive function after treatment. 
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...In summary, this is the first study to examine the association of anaesthesia-ECT TI with ECT treatment outcomes. Findings from a large clinical cohort of patients, treated with ECT for a range of psychiatric disorders, suggest that a longer TI leads to higher quality seizures, with greater impact on cognition, as would be expected with enhanced ECT dosing, but an association with treatment effectiveness was not demonstrated. The naturalistic treatment approach in this clinical sample may have obscured an association with treatment effectiveness. Future randomized control trials may help to clarify the potential effect of anaesthesia-ECT TI on ECT response and cognitive function.

This  is a large, retrospective study on a topic of modest-moderate interest and importance. It suffers from the usual limitations of a retrospective chart review, plus the use of somewhat crude assessment instruments. As noted, it is unfortunate that the outcome was assessed after 6 ECT, when fewer than 20% of patients had remitted.The conclusions of better seizure quality, no change in efficacy and a possible slight negative impact on short-term cognition with longer anesthesia-ECT TI are not surprising.
ECT is remarkably safe and effective when done properly, such that herculean efforts to make it a bit better, are only justified if they do not compromise safety/tolerability or drain otherwise better-used resources. Lengthening the anesthesia-ECT TI might risk increasing the incidence of awareness episodes (particularly with propofol), so one needs to be very cautious about this.
For ECT anesthesia mavens/gurus this paper should be read in full (~15 minutes).

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