Bifrontal ECT for PD: New Small Study
Out on PubMed, from investigators in Vancouver, Canada, is this study:
Psychiatric, Motor, and Autonomic Effects of Bifrontal ECT in Depressed Parkinson'sDisease Patients.
The abstract is copied below:
Objective: Depressive symptoms are a source of significant morbidity in Parkinson's disease (PD). Electroconvulsive therapy (ECT) is a promising treatment for depression in PD (dPD); however, data remain limited, including data on optimal electrode placement. In this retrospective study, the investigators aimed to characterize the effects of bifrontal ECT for dPD on psychiatric and motor symptoms, as well as autonomic response.
Methods: Clinical data were retrieved from a university-affiliated ECT service in Vancouver, British Columbia, for patients with dPD receiving bifrontal ECT between 2014 and 2018. Clinical Global Impression (depressive symptoms) and Unified Parkinson's Disease Rating Scale (motor symptoms) scores and cardiovascular measurements during ECT, as well as doses of dopaminergic medications, were recorded.
Results: Eight patients met criteria for inclusion. Six patients (75%) met response criteria for improvement of depressive symptoms, including 83% of patients who completed a full ECT course. Five patients went on to receive maintenance ECT, with only one patient relapsing by the 1-year follow-up (20%). For patients with motor scales reported, 60% showed a clinically significant improvement in motor symptoms. Among patients who completed ECT, a reduction in the median dopaminergic medication dose was also observed (-350 mg). Two patients discontinued ECT as a result of tolerability concerns. Participants demonstrated a relatively typical pattern of autonomic response to ECT, with low incidence of bradycardic events.
Conclusions: The results provide preliminary evidence of the benefit of bifrontal ECT in dPD for both depressive and motor symptoms. The autonomic data suggest that most patients with dPD respond in a typical physiological manner to ECT stimulus; however, further investigation is needed.
Keywords: Autonomic Nervous System; Depression; ECT; Motor Symptoms; Parkinson’s Disease.
And from the text:
Future Directions: Despite growing evidence for ECT’s effectiveness in dPD, concerns about adverse effects and stigma (31) may be limiting uptake. Determination of optimal electrode placement and identification of patients at higher risk for adverse events are important further areas of investigation, which may improve acceptability. More study of autonomic data is necessary to better understand the relationship between autonomic response and both tolerability and efficacy. Ultimately, randomized controlled studies are needed to establish the true efficacy and tolerability of this procedure in dPD, including the comparative performance of different electrode placements, and to investigate associations with autonomic response and neurocognitive effects.
Any data on ECT in Parkinson's disease (PD) are welcome. This was a very small (n=8), retrospective study, with incomplete data availability. Still, it showed the expected improvement in both depressive and motor symptoms in the majority of patients. The idea that bifrontal electrode placement is distinctly better than bilateral seems a bit of a stretch; more of a way to get published, by saying this study is a "first". The focus on pattern of changes in autonomic response over a course of ECT is also not particularly informative.
Psychiatric, Motor, and Autonomic Effects of Bifrontal ECT in Depressed Parkinson'sDisease Patients.
J Neuropsychiatry Clin Neurosci. 2021 Feb 25:appineuropsych20050133. doi: 10.1176/appi.neuropsych.20050133. Online ahead of print.PMID: 33626885
Objective: Depressive symptoms are a source of significant morbidity in Parkinson's disease (PD). Electroconvulsive therapy (ECT) is a promising treatment for depression in PD (dPD); however, data remain limited, including data on optimal electrode placement. In this retrospective study, the investigators aimed to characterize the effects of bifrontal ECT for dPD on psychiatric and motor symptoms, as well as autonomic response.
Methods: Clinical data were retrieved from a university-affiliated ECT service in Vancouver, British Columbia, for patients with dPD receiving bifrontal ECT between 2014 and 2018. Clinical Global Impression (depressive symptoms) and Unified Parkinson's Disease Rating Scale (motor symptoms) scores and cardiovascular measurements during ECT, as well as doses of dopaminergic medications, were recorded.
Results: Eight patients met criteria for inclusion. Six patients (75%) met response criteria for improvement of depressive symptoms, including 83% of patients who completed a full ECT course. Five patients went on to receive maintenance ECT, with only one patient relapsing by the 1-year follow-up (20%). For patients with motor scales reported, 60% showed a clinically significant improvement in motor symptoms. Among patients who completed ECT, a reduction in the median dopaminergic medication dose was also observed (-350 mg). Two patients discontinued ECT as a result of tolerability concerns. Participants demonstrated a relatively typical pattern of autonomic response to ECT, with low incidence of bradycardic events.
Conclusions: The results provide preliminary evidence of the benefit of bifrontal ECT in dPD for both depressive and motor symptoms. The autonomic data suggest that most patients with dPD respond in a typical physiological manner to ECT stimulus; however, further investigation is needed.
Keywords: Autonomic Nervous System; Depression; ECT; Motor Symptoms; Parkinson’s Disease.
And from the text:
Future Directions: Despite growing evidence for ECT’s effectiveness in dPD, concerns about adverse effects and stigma (31) may be limiting uptake. Determination of optimal electrode placement and identification of patients at higher risk for adverse events are important further areas of investigation, which may improve acceptability. More study of autonomic data is necessary to better understand the relationship between autonomic response and both tolerability and efficacy. Ultimately, randomized controlled studies are needed to establish the true efficacy and tolerability of this procedure in dPD, including the comparative performance of different electrode placements, and to investigate associations with autonomic response and neurocognitive effects.
Any data on ECT in Parkinson's disease (PD) are welcome. This was a very small (n=8), retrospective study, with incomplete data availability. Still, it showed the expected improvement in both depressive and motor symptoms in the majority of patients. The idea that bifrontal electrode placement is distinctly better than bilateral seems a bit of a stretch; more of a way to get published, by saying this study is a "first". The focus on pattern of changes in autonomic response over a course of ECT is also not particularly informative.
The authors' call for larger studies, with the ultimate goal of greater acceptance of ECT for PD, is laudable, but nothing new. It is hard to imagine what might eventually happen to facilitate such studies. As I wrote previously in this blog (December 14, 2020),
"about 10 years ago, a group of us applied for a grant to study ECT for PD from the Michael J. Fox Foundation, but were rejected. It is likely that antipathy to ECT in the Neurology community specifically, and the stigma surrounding ECT generally, are depriving many more advanced PD patients from benefitting from the treatment."
This new study is worth reading if you are interested in ECT for PD, ~10 minutes.
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