ECT, Electric Field, Neuroplasticity, and Clinical Outcomes

Out on PubMed, from US investigators, is this paper:

Electroconvulsive therapy, electric field, neuroplasticity, and clinical outcomes.

Deng ZD, Argyelan M, Miller J, Quinn DK, Lloyd M, Jones TR, Upston J, Erhardt E, McClintock SM, Abbott CC.Mol Psychiatry. 2021 Dec 1. doi: 10.1038/s41380-021-01380-y. Online ahead of print.PMID: 34853404



The abstract is copied below:
Electroconvulsive therapy (ECT) remains the gold-standard treatment for patients with depressive episodes, but the underlying mechanisms for antidepressant response and procedure-induced cognitive side effects have yet to be elucidated. Such mechanisms may be complex and involve certain ECT parameters and brain regions. Regarding parameters, the electrode placement (right unilateral or bitemporal) determines the geometric shape of the electric field (E-field), and amplitude determines the E-field magnitude in select brain regions (e.g., hippocampus). Here, we aim to determine the relationships between hippocampal E-field strength, hippocampal neuroplasticity, and antidepressant and cognitive outcomes. We used hippocampal E-fields and volumes generated from a randomized clinical trial that compared right unilateral electrode placement with different pulse amplitudes (600, 700, and 800 mA). Hippocampal E-field strength was variable but increased with each amplitude arm. We demonstrated a linear relationship between right hippocampal E-field and right hippocampal neuroplasticity. Right hippocampal neuroplasticity mediated right hippocampal E-field and antidepressant outcomes. In contrast, right hippocampal E-field was directly related to cognitive outcomes as measured by phonemic fluency. We used receiver operating characteristic curves to determine that the maximal right hippocampal E-field associated with cognitive safety was 112.5 V/m. Right hippocampal E-field strength was related to the whole-brain ratio of E-field strength per unit of stimulation current, but this whole-brain ratio was unrelated to antidepressant or cognitive outcomes. We discuss the implications of optimal hippocampal E-field dosing to maximize antidepressant outcomes and cognitive safety with individualized amplitudes.






This is a sophisticated study that attempts to move towards individualized stimulus dosing in ECT, based on E-fields and their relationship to neuroplasticity and cognitive effects. The results (see above) are informative and will likely lead to more research that will be translatable to clinical ECT.
My one beef with the article is the use of the term, "cognitive safety." In medicine, "safety" refers to the possibility of physical injury or death; transient cognitive effects, mostly mild-moderate, should correctly be called a "tolerability" issue. Labeling cognitive effects as a safety issue plays into the hands of the anti-ECT activists.
All ECT practitioners should read this paper in full (Figure 2 alone (see above) is worth the price of admission), ~25 minutes.

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