Keith G. Rasmussen

ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE.

Objective To compare the relative efficacy of electroconvulsive therapy (ECT) in psychotic and nonpsychotic patients with unipolar major depression. Methods The outcome of an acute ECT course in 253 patients with nonpsychotic (n = 176) and psychotic (n = 77) unipolar major depression was assessed in the first phase of an ongoing National Institute of Mental Health-supported four-hospital collaborative study of continuation treatments after successful ECT courses. ECT was administered with bilateral electrode placement at 50% above the titrated seizure threshold. The remission criteria were rigorous: a score ≤10 on the 24-item Hamilton Rating Scale for Depression (HRSD) after 2 consecutive treatments, and a decrease of at least 60% from baseline. Results The overall remission rate was 87% for study completers. Among these, patients with psychotic depression had a remission rate of 95% and those with nonpsychotic depression, 83%. Improvement in symptomatology, measured by the HRSD, was more robust and appeared sooner in the psychotic patients compared with the nonpsychotic patients. Conclusion Bilateral ECT is effective in relieving severe major depression. Remission rates are higher and occur earlier in psychotic depressed patients than in nonpsychotic depressed patients. These data support the argument that psychotic depression is a distinguishable nosological entity that warrants separate treatment algorithms.

Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial

BACKGROUND Electroconvulsive therapy (ECT) is an effective treatment for major depression. Optimising efficacy and minimising cognitive impairment are goals of ongoing technical refinements. AIMS To compare the efficacy and cognitive effects of a novel electrode placement, bifrontal, with two standard electrode placements, bitemporal and right unilateral in ECT. METHOD This multicentre randomised, double-blind, controlled trial (NCT00069407) was carried out from 2001 to 2006. A total of 230 individuals with major depression, bipolar and unipolar, were randomly assigned to one of three electrode placements during a course of ECT: bifrontal at one and a half times seizure threshold, bitemporal at one and a half times seizure threshold and right unilateral at six times seizure threshold. RESULTS All three electrode placements resulted in both clinically and statistically significant antidepressant outcomes. Remission rates were 55% (95% CI 43-66%) with right unilateral, 61% with bifrontal (95% CI 50-71%) and 64% (95% CI 53-75%) with bitemporal. Bitemporal resulted in a more rapid decline in symptom ratings over the early course of treatment. Cognitive data revealed few differences between the electrode placements on a variety of neuropsychological instruments. CONCLUSIONS Each electrode placement is a very effective antidepressant treatment when given with appropriate electrical dosing. Bitemporal leads to more rapid symptom reduction and should be considered the preferred placement for urgent clinical situations. The cognitive profile of bifrontal is not substantially different from that of bitemporal.

Serial infusions of low-dose ketamine for major depression

Background: Single infusions of ketamine have been used successfully to achieve improvement in depressed patients. Side effects during the infusions have been common. It is not known whether serial infusions or lower infusion rates result in greater efficacy. Methods: Ten depressed patients were treated with twice weekly ketamine infusions of ketamine 0.5 mg/kg administered over 100 min until either remission was achieved or four infusions were given. Side effects were assessed with the Young Mania Rating Scale (YMRS) and the Brief Psychiatric Rating Scale (BPRS). Patients were followed naturalistically at weekly intervals for four weeks after completion of the infusions. Results: Five of 10 patients achieved remission status. There were no significant increases on the BPRS or YMRS. Two of the remitting patients sustained their improvement throughout the four week follow-up period. Conclusions: Ketamine infusions at a lower rate than previously reported have demonstrated similar efficacy and excellent tolerability and may be more practically available for routine clinical care. Serial ketamine infusions appear to be more effective than a single infusion. Further research to test relapse prevention strategies with continuation ketamine infusions is indicated.

Morbidity and Mortality in the Use of Electroconvulsive Therapy

There are a few large studies of the morbidity and mortality of electroconvulsive therapy (ECT). To add data to this literature, we performed a retrospective review of all the patients who underwent ECT at our institution between January 1, 1988, through December 31, 2001. We identified 2,279 patients who were given 17,394 ECT treatments during their first series. The median number of treatments received per patient was 7. Twenty-one patients (0.92%) experienced a complication at some time during their first series of ECT treatments. Cardiac complications, mostly arrhythmias, constituted the majority. However, none of the complications caused permanent injury, and none of the patients died during or immediately after ECT. There were 18 deaths within 30 days of the final treatment, none related to ECT. These data are concordant with those of other published large series, and we conclude that ECT is an extremely safe procedure.

Long-term maintenance ECT: a retrospective review of efficacy and cognitive outcome.

Continuation and maintenance electroconvulsive therapy (ECT) are used to prevent relapse of depression after a successful course of index ECT. Such a course of treatment is typically extended for as long as a year. However, some patients seem to require longer courses of maintenance ECT. Little is known about the outcomes of long-term use (> 1 year) of maintenance ECT. We reviewed our maintenance ECT practice for the year 2000 and found that 43 patients had been receiving maintenance ECT for more than a year. This retrospective study reviews the outcomes of these patients. All patients had depression associated with either unipolar or bipolar disorder or schizoaffective disorder. These patients had multiple medication or psychotherapy trials or both and multiple hospitalizations before receiving maintenance ECT. Effects on depressive symptoms, level of functioning, health care use, frequency of hospitalizations, and cognition are discussed. We conclude that extended maintenance ECT is efficacious and well tolerated and reduces hospital use for a population of chronically depressed patients refractory to medication.

Electroconvulsive therapy is equally effective in unipolar and bipolar depression

Bailine S, Fink M, Knapp R, Petrides G, Husain MM, Rasmussen K, Sampson S, Mueller M, McClintock SM, Tobias KG, Kellner CH. Electroconvulsive therapy is equally effective in unipolar and bipolar depression.

Electroconvulsive therapy for phantom limb pain

Phantom limb pain is common in amputees. Although several treatments are available, a significant number of patients are refractory. Electroconvulsive therapy (ECT), which is usually given to patients with psychiatric disorders such as major depression, has shown efficacy in patients with a variety of pain syndromes occurring along with depression. Two patients are described herein with severe phantom limb pain refractory to multiple therapies, without concurrent psychiatric disorder, who received ECT. Both patients enjoyed substantial pain relief. In one case, phantom pain was still in remission 3.5 years after ECT. It is concluded that phantom limb patients who are refractory to multiple therapies may respond to ECT.

Decisional capacity of severely depressed patients requiring electroconvulsive therapy.

Objective The decisional capacity of severely depressed people frequently comes into question. The ability to improve this decisional capacity through educational efforts alone is not known. Our study aimed to determine the decisional capacity of severely depressed people requiring electroconvulsive therapy (ECT), and whether educational interventions improve their ability to provide informed consent for ECT. Materials and Methods Forty subjects with severe depression were recruited. Using the MacArthur Competence Assessment Tool for Treatment instrument, decisional capacity was assessed at baseline and reassessed after education. All of the subjects received standard education. Additionally, half were blindly randomized to receive an experimental educational intervention. Results At baseline, there was no statistical difference in the decisional capacity between the standard and experimental intervention groups. After educational interventions, all four areas of decisional capacity improved for both groups (understanding p < 0.001, reasoning p < 0.001, appreciation p = 0.031, choice p = 0.006). However, there was no measurable additional improvement in scores for those randomized to receive additional education. Conclusion Our findings indicate that this group of severely depressed people had good decisional capacities to give informed consent. Education improved their decisional capacity. There is an endpoint beyond which additional educational intervention does not result in measurable improvement in decisional capacity.

A randomized comparison of ketamine versus methohexital anesthesia in electroconvulsive therapy.

To assess the clinical utility of ketamine as an anesthetic agent for electroconvulsive therapy (ECT), based upon recent findings that ketamine may have antidepressant properties. Depressed ECT patients were randomly assigned to receive anesthesia with either ketamine or methohexital. Outcome measures included assessments of depressive severity, cognition, post-anesthesia side effects, and hemodynamics. Twenty one patients were treated with ketamine and 17 with methohexital. There were no significant differences in depression or cognitive outcomes between the two drugs. Additionally, there were no measures of post-anesthesia tolerability or hemodynamics which favored ketamine. Ketamine anesthesia does not accelerate the antidepressant effect of ECT or diminish the cognitive side effects, at least as measured in this study. Furthermore, there is no apparent benefit of ketamine for speed or quality of post-ECT recovery, and it is associated with higher systolic blood pressures after the treatments. Ketamine is associated with longer motor seizure duration than methohexital.

The safety of electroconvulsive therapy and lithium in combination: a case series and review of the literature.

Early reports cautioned against the combination of lithium and electroconvulsive therapy (ECT), citing risk of excessive cognitive disturbance, prolonged apnea, and spontaneous seizures. However, recent case series with larger numbers of patients indicate that the combination may be used safely and with optimal efficacy in certain clinical circumstances. In this report, we describe 12 patients in whom the combination of lithium and ECT was deemed safe. We also provide a comprehensive review of published literature and provide detailed recommendations for clinical practice.