Anaesthesia for electroconvulsive therapy – new tricks for old drugs: a systematic review

ObjectiveThe objective of this review is to investigate existing literature in order to delineate whether the use of anaesthesia and timing of seizure induction in a new and optimised way may improve the efficacy of electroconvulsive therapy (ECT).MethodsPubMed/MEDLINE was searched for existing literature, last search on 24 June 2015. Relevant clinical studies on human subjects involving choice of anaesthetic, ventilation and bispectral index (BIS) monitoring in the ECT setting were considered. The references of relevant studies were likewise considered.ResultsPropofol yields the shortest seizures, etomidate and ketamine the longest. Etomidate and ketamine+propofol 1 : 1 seems to yield the seizures with best quality. Seizure quality is improved when induction of ECT is delayed until the effect of the anaesthetic has waned – possibly monitored with BIS values. Manual hyperventilation with 100% O2 may increase the pO2/pCO2-ratio, which may be correlated with better seizure quality.ConclusionEtomidate or a 1 : 1 ketamine and propofol combination may be the best method to achieve general anaesthesia in the ECT setting. There is a need for large randomised prospective studies comparing the effect of methohexital, thiopental, propofol, ketamine, propofol+ketamine 1 : 1 and etomidate in the ECT treatment of major depressed patients. These studies should investigate safety and side effects, and most importantly have antidepressant efficacy and cognitive side effects as outcome measures instead of seizure quality.

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Technical Aspects of Electroconvulsive Therapy: An Update

European Psychiatry ◽

10.1016/s0924-9338(09)70305-0 ◽

2009 ◽

Vol 24 (S1) ◽

pp. 1-1

Author(s):

P. Sienaert

Keyword(s):

Side Effects ◽

Electroconvulsive Therapy ◽

Pulse Width ◽

Additional Treatment ◽

Electrode Placement ◽

Treatment Conditions ◽

Antidepressant Efficacy ◽

Remission Criteria ◽

Standard Pulse ◽

Cognitive Side Effects

In an ongoing attempt to improve efficacy of electroconvulsive therapy (ECT) while minimizing side-effects, both different electrode placements and stimulus parameters have been studied. It has been shown that the traditional bitemporal electrode placement and modern techniques such as bifrontal and unilateral ECT are efficacious, depending on the stimulus used. Modern ECT-devices deliver a square wave brief pulse stimulus. An unresolved issue in the use of brief pulse stimulation concerns the optimal pulse width. It has been suggested that the use of a stimulus with an ultra brief (UB) pulse width, i.e. 0.3 ms, is substantially more efficient in seizure induction, thus needing less energy, and producing less cognitive side-effects than standard pulse width (i.e. 0.5-2 ms) stimulation. There has been a concern, however, of lower antidepressant efficacy of UB ECT, with patients needing additional treatment sessions. Moreover, it has been suggested that the diminished antidepressive efficacy is encountered solely with the combination of an ultra-brief pulse width and bilateral electrode placement, as compared to unilateral UB ECT or standard pulse ECT. In a randomized trial, the antidepressive efficacy and cognitive side-effects of bifrontal and right unilateral UB ECT were compared. It was shown that, using an ultra-brief pulse width, BF ECT is as efficacious as UL ECT, although patients receiving UL ECT achieved response/remission-criteria after a smaller number of treatments. In both treatment conditions there was an improvement of cognitive function, both during and after the treatment course.

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Acetylcholinesterase inhibitors for electroconvulsive therapy-induced cognitive side effects: a systematic review

International Journal of Geriatric Psychiatry ◽

10.1002/gps.4702 ◽

2017 ◽

Vol 32 (5) ◽

pp. 522-531 ◽

Cited By ~ 8

Author(s):

Marieke J. Henstra ◽

Elise P. Jansma ◽

Nathalie van der Velde ◽

Eleonora L. Swart ◽

Max L. Stek ◽

...

Keyword(s):

Systematic Review ◽

Side Effects ◽

Electroconvulsive Therapy ◽

Acetylcholinesterase Inhibitors ◽

Cognitive Side Effects

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The Neurobiological Basis of Cognitive Side Effects of Electroconvulsive Therapy: A Systematic Review

Brain Sciences ◽

10.3390/brainsci11101273 ◽

2021 ◽

Vol 11 (10) ◽

pp. 1273

Author(s):

Adriana Bassa ◽

Teresa Sagués ◽

Daniel Porta-Casteràs ◽

Pilar Serra ◽

Erika Martínez-Amorós ◽

...

Keyword(s):

Systematic Review ◽

Side Effects ◽

Electroconvulsive Therapy ◽

Cell Damage ◽

Neuron Specific Enolase ◽

Predictive Biomarkers ◽

Current Evidence ◽

Functional Changes ◽

Concentration Changes ◽

Cognitive Side Effects

Decades of research have consistently demonstrated the efficacy of electroconvulsive therapy (ECT) for the treatment of major depressive disorder (MDD), but its clinical use remains somewhat restricted because of its cognitive side effects. The aim of this systematic review is to comprehensively summarize current evidence assessing potential biomarkers of ECT-related cognitive side effects. Based on our systematic search of human studies indexed in PubMed, Scopus, and Web of Knowledge, a total of 29 studies evaluating patients with MDD undergoing ECT were reviewed. Molecular biomarkers studies did not consistently identify concentration changes in plasma S-100 protein, neuron-specific enolase (NSE), or Aβ peptides significantly associated with cognitive performance after ECT. Importantly, these findings suggest that ECT-related cognitive side effects cannot be explained by mechanisms of neural cell damage. Notwithstanding, S-100b protein and Aβ40 peptide concentrations, as well as brain-derived neurotrophic factor (BDNF) polymorphisms, have been suggested as potential predictive biomarkers of cognitive dysfunction after ECT. In addition, recent advances in brain imaging have allowed us to identify ECT-induced volumetric and functional changes in several brain structures closely related to memory performance such as the hippocampus. We provide a preliminary framework to further evaluate neurobiological cognitive vulnerability profiles of patients with MDD treated with ECT.

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Repetitive transcranial magnetic stimulation treatment for peripartum depression: systematic review & meta-analysis

BMC Pregnancy and Childbirth ◽

10.1186/s12884-021-03600-3 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Hyune June Lee ◽

Sung Min Kim ◽

Ji Yean Kwon

Keyword(s):

Systematic Review ◽

Transcranial Magnetic Stimulation ◽

Side Effects ◽

Electroconvulsive Therapy ◽

Effect Size ◽

Magnetic Stimulation ◽

Repetitive Transcranial Magnetic Stimulation ◽

Meta Analysis ◽

Cochrane Library ◽

Peripartum Depression

Abstract Background Peripartum depression is a common disorder with very high potential hazards for both the patients and their babies. The typical treatment options include antidepressants and electroconvulsive therapy. However, these treatments do not ensure the safety of the fetus. Recently, repetitive transcranial magnetic stimulation has emerged as a promising treatment for neuropathies as well as depression. Nevertheless, many studies excluded pregnant women. This systematic review was conducted to confirm whether repetitive transcranial magnetic stimulation was a suitable treatment option for peripartum depression. Methods We performed a systematic review that followed the PRISMA guidelines. We searched for studies in the MEDLINE, PsycINFO, EMBASE, and Cochrane library databases published until the end of September 2020. Eleven studies were selected for the systematic review, and five studies were selected for quantitative synthesis. Data analysis was conducted using Comprehensive Meta-Analysis 3 software. The effect size was analyzed using the standardized mean difference, and the 95% confidence interval (CI) was determined by the generic inverse variance estimation method. Results The therapeutic effect size of repetitive transcranial magnetic stimulation for peripartum depression was 1.394 (95% CI: 0.944–1.843), and the sensitivity analysis effect size was 1.074 (95% CI: 0.689–1.459), indicating a significant effect. The side effect size of repetitive transcranial magnetic stimulation for peripartum depression was 0.346 (95% CI: 0.214–0.506), a meaningful result. There were no severe side effects to the mothers or fetuses. Conclusions From various perspectives, repetitive transcranial magnetic stimulation can be considered an alternative treatment to treat peripartum depression to avoid exposure of fetuses to drugs and the severe side effects of electroconvulsive therapy. Further research is required to increase confidence in the results.

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The Cognitive Side Effects of Electroconvulsive Therapy.

Annals of the New York Academy of Sciences ◽

10.1111/j.1749-6632.1986.tb51269.x ◽

1986 ◽

Vol 462 (1 Electroconvul) ◽

pp. 353-356 ◽

Cited By ~ 5

Author(s):

STEPHANIE PORTNOY

Keyword(s):

Side Effects ◽

Electroconvulsive Therapy ◽

Cognitive Side Effects

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Alfentanil anesthetic augmentation lengthens seizure duration in electroconvulsive therapy with older people

International Psychogeriatrics ◽

10.1017/s1041610216000119 ◽

2016 ◽

Vol 28 (6) ◽

pp. 1051-1052

Author(s):

Craig D'Cunha ◽

Christos Plakiotis ◽

Daniel W. O'Connor

Keyword(s):

Side Effects ◽

Older People ◽

Electroconvulsive Therapy ◽

Electrode Placement ◽

Seizure Threshold ◽

Dose Titration ◽

Seizure Duration ◽

New Learning ◽

Prescription Rates ◽

Cognitive Side Effects

Electroconvulsive therapy (ECT) prescription rates rise with age, making it important that treatments be made as effective and safe as possible (Plakiotis et al., 2012). Older people are vulnerable to post-treatment confusion and to subsequent deficits in attention, new learning, and autobiographical memory (Gardner and O'Connor, 2008). Strategies to minimize cognitive side-effects include unilateral electrode placement and stimulus dose titration whereby electrical charge is individually calibrated to seizure threshold (Sackeim et al., 2000). It remains the case, however, that threshold levels typically rise over the treatment course, leading to an increase both in delivered charge and the risk of adverse sequelae.

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