Kristen G. Tobias

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.

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.

Continuation and maintenance electroconvulsive therapy for mood disorders: review of the literature.

Background: Electroconvulsive therapy (ECT) is a highly effective treatment for mood disorders. Continuation ECT (C-ECT) and maintenance ECT (M-ECT) are required for many patients suffering from severe and recurrent forms of mood disorders. This is a review of the literature regarding C- and M-ECT. Methods: We conducted a computerized search using the words continuation ECT, maintenance ECT, depression, mania, bipolar disorder and mood disorders. We report on all articles published in the English language from 1998 to 2009. Results: We identified 32 reports. There were 24 case reports and retrospective reviews on 284 patients. Two of these reports included comparison groups, and 1 had a prospective follow-up in a subset of subjects. There were 6 prospective naturalistic studies and 2 randomized controlled trials. Conclusions: C-ECT and M-ECT are valuable treatment modalities to prevent relapse and recurrence of mood disorders in patients who have responded to an index course of ECT. C-ECT and M-ECT are underused and insufficiently studied despite positive clinical experience of more than 70 years. Studies which are currently under way should allow more definitive recommendations regarding the choice, frequency and duration of C-ECT and M-ECT following acute ECT.

Resolution of Severe Suicidality With a Single Electroconvulsive Therapy

Electroconvulsive therapy is a rapid and effective treatment of severe depression that has been shown to quickly decrease or eliminate suicidal thoughts and behaviors. We describe the case of an 88-year-old man hospitalized for a carefully premeditated suicide attempt with highly lethal means. He was treated with a single electroconvulsive therapy (ECT) and improved markedly. His suicidal ideation remitted, and the patient was still free of suicidal ideation at 5 months of follow-up. We discuss the effect of ECT on suicidal ideation, the benefit of minimizing the number of total ECT treatments, and the possible biological markers of change after a single treatment in an ECT-naive patient.

Cognitive Tolerability of Electroconvulsive Therapy in a Patient With a History of Traumatic Brain Injury

We present the case of a 28-year-old male with a history of a severe closed head injury who successfully underwent electroconvulsive therapy for treatment of his depression. A detailed neuropsychological evaluation demonstrated the cognitive tolerability of the treatment. We review the literature on electroconvulsive therapy and brain injury.

Tinnitus as a symptom of psychotic depression successfully treated with electroconvulsive therapy.

We present the case of a 51-year-old woman with recurrent major depression with psychotic features including severe tinnitus. Her tinnitus resolved with successful treatment of her depressive episode with electroconvulsive therapy. We review the literature on electroconvulsive therapy and tinnitus.

A 42-second seizure in a 24-year-old man with major depressive disorder.

CLINICAL INFORMATION The patient was a 24-year-old man with a diagnosis of severe, recurrent major depressive disorder. He had a history of inadequate response to multiple medication trials. He had no medical problems and was right-handed. Concurrent medications were 40 mg citalopram and 25 Kg liothyronine sodium. Anesthesia was with 0.2 mg glycopyrrolate, 90 mg propofol, and 60 mg succinylcholine. Ketorolac (30-mg intravenously) was given as pretreatment for headache prophylaxis. TECHNICAL PARAMETERS This tracing was obtained using a Thymatron System IV device (Somatics, LLC, Lake Bluff, Ill) at treatment No. 12. Electroencephalogram 1 (EEG1) is left frontomastoid, whereas EEG2 is right frontomastoid. Electrode placement was right unilateral (d’Elia placement). Stimulus dosing was at 75% energy (charge, 370.2 millicoulombs; current, 0.88 A; stimulus duration, 7.6 seconds; frequency, 110 Hz; pulse width, 0.25 milliseconds; static impedance, 2490 6; dynamic impedance, 310 6). Seizure durations, as read by the device, were 42 seconds (electromyogram endpoint) and 76 seconds (EEG endpoint). Clinical reading was 42 seconds (electromyogram endpoint) and 80 seconds (EEG endpoint). Ictal EEG data parameters, as calculated by the device, included early ictal amplitude, 131.9 KV; midictal amplitude, 247.6 KV; and postictal suppression index, 76.4%. Base heart rate was 68 beats per minute, and peak was 124 beats per minute. FIGURE 1. A, Seizure initiation. B, End of the motor seizure at 42 seconds. C, End of the EEG seizure at 76 seconds.

Electroconvulsive therapy for an urgent social indication.

Electroconvulsive therapy (ECT) is often rapidly effective in relieving the symptoms of severe depression. We report the case of a female patient with recurrent depression whose family desperately wanted her to be well enough to participate in her daughters wedding. They contacted our ECT service only days before the wedding. After a single bifrontal ECT, she was able to attend and enjoy this important family function. We review the literature on speed of response to ECT and the effect of a single ECT.