Robert M. Greenberg

Determinants of seizure threshold in ECT: Benzodiazepine use, anesthetic dosage, and other factors

The electrical dosage of the ECT stimulus impacts on efficacy and cognitive side effects, yet seizure threshold (ST) may vary as much as 50-fold across patients. It would be desirable to predict ST on the basis of patient and treatment characteristics. In particular, concerns have been raised that benzodiazepine use and higher dosage of barbiturate anesthetics elevate ST. In a three-site study, ST was quantified at the first ECT session using an identical empirical titration procedure in 294 patients who met RDC and DSM-IIIR criteria for a major depressive episode. ST varied over a 35-fold range across patients treated with right unilateral (RUL) (n = 267) and bilateral (BL) (n = 27) ECT. Higher ST was associated with BL electrode placement (p = 0.001). Among patients treated with RUL ECT, univariate analyses indicated that higher ST was associated with advanced age (p < 0.001), male gender (p < 0.001), greater burden of medical illness (p < 0.001), weight (p < 0.01), duration of mood disorder (p < 0.01), and history of previous ECT (p < 0.05). Average lorazepam dose in the 48 hours prior to ECT was not associated with ST, but was associated with decreased seizure duration (p < 0.01). Absolute, but not weight-adjusted, methohexital dose was associated with ST (p < 0.01). Multivariate analyses in patients treated with unilateral ECT showed that only 27.6% of the variance in ST (p < 0.0001) could be predicted. In the multivariate analyses, only age (p = 0.0001), gender (p = 0.01), and methohexital dose (p = 0.0001) were independently related to ST. Low dosage of lorazepam and methohexital dosage below 1 mg/kg are unlikely to impact on ST. Given the limited capacity to predict ST, empirical titration remains the only accurate method to determine electrical dosage in RUL ECT.

ECT in treatment-resistant depression.

Electroconvulsive therapy (ECT), which has been in use for 75 years, is an important treatment for severe and treatment-resistant depression. Although it is acknowledged as the most effective acute treatment for severe mood and psychotic disorders, it remains controversial because of misperceptions about its use and lack of familiarity among health care professionals about modern ECT technique. The authors present an illustrative case of a patient for whom ECT is indicated. They review the basic and clinical science related to ECTs mechanism of action and discuss clinical issues in the administration of a course of ECT, including the consent process.

Electroconvulsive Therapy is a Standard Treatment; Ketamine is Not (Yet)

To The Editor: Alan Schatzberg’s commentary in the March issue, “A Word to the Wise About Ketamine” (1), urges caution in the clinical use of ketamine pending further research and data collection. We agree with this position and would like to share our clinical experience with seriously depressed patients who have received ketamine infusions prior to electroconvulsive therapy (ECT) referral. In the last year, we have seen at least half a dozen patients who, when they presented for ECT consultation, gave histories of having had either single or repeated ketamine infusions at a private anesthesiologist’s office in New York City. These patients had either no, or very transient, antidepressant benefit from the ketamine or unpleasant adverse effects (mainly dissociative); they were subsequently referred by their psychiatrists for consideration of ECT. Most of these patients were profoundly depressed, and some were suicidal. If a ketamine challenge is to become a standard step in the treatment algorithm for treatmentresistant depression, the risks of not just the ketamine itself, but the delay in definitive treatment, must be taken into account. Seriously depressed patients who have failed to respond to one or more antidepressant medication trials should be referred for ECT consultation, sooner rather than later, to ensure optimal outcomes. Suicide risk in this population is elevated, as is the potential for ongoing medical morbidity, not to mention the continued suffering from the depressive episode itself. A recent study (2) comparing three ketamine infusions with three ECT treatments in 1 week touted ketamine as a superior treatment and received considerable media attention (3). A reasonable interpretation of that research is that it replicated the finding of a signal of early antidepressant responsewith ketamine.However, ketamine remains completely unproven as a definitive treatment for a major depressive episode. Seriously ill psychiatric patients are often desperate for dramatic cures; their health care providers, acknowledging that our current treatments are often lacking, are also eager for the newest breakthroughs. Such desperation and enthusiasm should not cloud our clinical judgment; proven, evidence-based treatments, including ECT for seriously depressed patients, should be offered before unproven, experimental approaches, nomatter how “in vogue” those approaches may be.

Effects of a right unilateral ultrabrief pulse electroconvulsive therapy course on health related quality of life in elderly depressed patients

INTRODUCTION Patients with Major Depressive Disorder (MDD) referred for electroconvulsive therapy (ECT) have poorer Health Related Quality of Life (HRQOL), compared with other patients with MDD, but ECT is associated with significant and durable improvement in HRQOL. However, no prior research has focused exclusively on elderly patients with MDD receiving ECT. METHODS HRQOL data from 240 depressed patients over the age of 60 was measured with the Medical Outcomes Study Short Form 36 (SF-36). The SF-36 was measured before and after a course of acute ECT. Predictors of change in HRQOL scores were identified by generalized linear modeling. RESULTS At baseline, participants showed very poor HRQOL. After treatment with ECT, the full sample showed marked and significant improvement across all SF-36 measures, with the largest gains seen in dimensions of mental health. Across all participants, the Physical Component Summary (PCS) score improved by 2.1 standardized points (95% CI, 0.61,3.56), while the Mental Component Summary (MCS) score improved by 12.5 points (95% CI, 7.2,10.8) Compared with non-remitters, remitters showed a trend toward greater improvement in the PCS summary score of 2.7 points (95%CI, -0.45, 5.9), while the improvement in the MCS summary score was significantly greater (8.5 points, 95% CI, 4.6,12.3) in the remitters than non-remitters. Post-ECT SF-36 measurements were consistently and positively related to baseline scores and remitter/non-remitter status or change in depression severity from baseline. Objective measures of cognitive function had no significant relationships to changes in SF-36 scores. LIMITATIONS This studys limitations include that it was an open label study with no comparison group, and generalizability is limited to elderly patients. DISCUSSION ECT providers and elderly patients with MDD treated with ECT can be confident that ECT will result in improved HRQOL in the short-term. Attaining remission is a key factor in the improvement of HRQOL. Acute changes in select cognitive functions were outweighed by improvement in depressive symptoms in determining the short term HRQOL of the participants treated with ECT.

More data on speed of remission with ECT in geriatric depression

We appreciate the important contribution of Spaans et al [1][1] to the evidence that electroconvulsive therapy (ECT) is a rapidly acting treatment in geriatric depression. Their data are a reminder that, despite the recent excitement about other neuromodulation modalities for the treatment of