A Systematic Review and Meta-Analysis of Brief Versus Ultrabrief Right Unilateral Electroconvulsive Therapy for Depression

Tor, Phern‐Chern; Bautovich, Alison; Wang, Min‐Jung; Martin, Donel; Harvey, Samuel B; Loo, Colleen

doi:10.4088/jcp.14r09145

Cited by 173 publications

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“…A lower proportion of the patients responded to the treatment (54% vs 66.7%). These findings align with those of the meta-analysis, 1 in which patients treated with UBP ECT received a significantly higher number of treatment sessions (9.6 vs 8.7) than patients treated with BP ECT.…”

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confidence: 88%

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The Ideal ECT Technique or the Ideal ECT Patient: What Should Be the Focus of Research?

Sienaert

2015

J. Clin. Psychiatry

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T he endeavor of Tor and colleagues 1 confirms the buzz that has been around for some time. Ultrabrief pulse (UBP) right unilateral (RUL) electroconvulsive therapy (ECT) is an attractive ECT technique, since it has a strong reputation of being cognitively safe. Its antidepressive efficacy, however, is less robust than that of standard brief pulse (BP) ECT. In a meta-analysis of 6 studies, comprising a total of 689 patients, Tor et al conclude that standard BP unilateral ECT is, indeed, significantly more efficacious than UBP ECT. The latter yields lower remission rates, with a number needed to treat of 12.1. BP RUL ECT, however, has significantly more cognitive side effects.Although the delicate balance between efficacy and side effect burden is not yet fully detailed, a substantial number of clinicians and clinics have made the transition toward the use of UBP ECT. Even in the most severely ill patients, those with chronic catatonia, this technique is advocated. [2][3][4] Interesting naturalistic data on the use of UBP ECT recently presented by Galletly and colleagues 5 shed some light on the possible consequences of changing treatment protocols. In a private psychiatric hospital, after the introduction of UBP ECT, patients received 2 treatment sessions more in a course and spent on average more than 5 days longer in the hospital with this technique compared to BP ECT. A lower proportion of the patients responded to the treatment (54% vs 66.7%). These findings align with those of the meta-analysis, 1 in which patients treated with UBP ECT received a significantly higher number of treatment sessions (9.6 vs 8.7) than patients treated with BP ECT.It seems that the field has shifted from preferring highly effective techniques and accepting the cognitive burden toward focusing on reducing cognitive side effects, even if the price is reduced efficacy. A similar evolution was seen in psychopharmacology, in which side effects of tricyclic antidepressants and lithium have been consistently exaggerated and their efficacy underestimated, while the opposite happened with the newer antidepressants. We should, nevertheless, continue to use the most efficacious treatment options, such as tricyclics, lithium, and bilateral standard pulse ECT, for our patients. It is of importance to note that most side effects of ECT are transient. 6 Sacrificing efficacy to avoid these transient side effects is perhaps not the best strategy to consider in some of the most severely ill patients we have under our care. As is shown in Tor and colleagues' meta-analysis, UBP ECT should not be the standard of care.In our clinic, where we have studied UBP ECT, 7-9 this technique is not used routinely. In selected cases in which avoiding cognitive side effects is a primary consideration, UBP ECT is a useful treatment alternative. An example is the case of a teacher who was treated for severe depression with suicidality that swiftly remitted with BP bifrontal ECT after several failed medication trials. After he relapsed, he refused a second course bec...

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confidence: 88%

“…he endeavor of Tor and colleagues 1 confirms the buzz that has been around for some time. Ultrabrief pulse (UBP) right unilateral (RUL) electroconvulsive therapy (ECT) is an attractive ECT technique, since it has a strong reputation of being cognitively safe.…”

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confidence: 75%

The Ideal ECT Technique or the Ideal ECT Patient: What Should Be the Focus of Research?

Sienaert

2015

J. Clin. Psychiatry

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“…In terms of harms/benefits ratio, high-dose unilateral ECT was noninferior to bitemporal ECT but showed a better cognitive profile, especially for preserving retrograde personal memories and fewer subjective cognitive side effects. While there is much interest in other modifications to maintain effectiveness but reduce side effects (e.g., ultrabrief pulse-width ECT), these require further refinement and characterization for optimization (36,37). Our findings justify considering high-dose unilateral ECT as the preferred ECT option for treating depression and may help improve acceptability and availability of this effective treatment.…”

Section: Discussionmentioning

confidence: 80%

Bitemporal Versus High-Dose Unilateral Twice-Weekly Electroconvulsive Therapy for Depression (EFFECT-Dep): A Pragmatic, Randomized, Non-Inferiority Trial

Semkovska¹,

Landau²,

Dunne³

et al. 2016

AJP

139

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Objective: ECT is the most effective treatment for severe depression. Previous efficacy studies, using thrice-weekly brief-pulse ECT, reported that high-dose (63 seizure threshold) right unilateral ECT is similar to bitemporal ECT but may have fewer cognitive side effects. The authors aimed to assess the effectiveness and cognitive side effects of twice-weekly moderate-dose (1.53 seizure threshold) bitemporal ECT with high-dose unilateral ECT in real-world practice.Method: This was a pragmatic, patient-and rater-blinded, noninferiority trial of patients with major depression (N=138; 63% female; age=56.7 years [SD=14.8]) in a national ECT service with a 6-month follow-up. Participants were independently randomly assigned to bitemporal or highdose unilateral ECT. The primary outcome was change in the 24-item Hamilton Depression Rating Scale (HAM-D) score after the ECT course; the prespecified noninferiority margin was 4.0 points. Secondary outcomes included response and remission rates, relapse status after 6 months, and cognition.Results: Of the eligible patients, 69 were assigned to bitemporal ECT and 69 to unilateral ECT. High-dose unilateral ECT was noninferior to bitemporal ECT regarding the 24-item HAM-D scores after the ECT course (mean difference=1.08 points in favor of unilateral ECT [95% CI=21.67 to 3.84]). There were no significant differences for response and remission or 6-month relapse status. Recovery of orientation was quicker following unilateral ECT (median=19.1 minutes versus 26.4 minutes). Bitemporal ECT was associated with a lower percent recall of autobiographical information (odds ratio=0.66) that persisted for 6 months.Conclusions: Twice-weekly high-dose unilateral ECT is not inferior to bitemporal ECT for depression and may be preferable because of its better cognitive side-effect profile.

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“…26,27 There have been recent claims for marked cognitive benefit from RUL ultra-brief-pulse ECT compared with both bilateral ultra-brief-pulse ECT and all types of brief-pulse ECT without sacrificing efficacy; 19,28 however, a recent meta-analysis of six studies, although confirming the cognitive advantage, found that it came at the price of lower efficacy than for bilateral brief-pulse ECT. 29 The role of glutamate in depression and the effects of electroconvulsive therapy…”

Section: Clinical Use Of Electroconvulsive Therapymentioning

confidence: 99%

Randomised controlled trial of ketamine augmentation of electroconvulsive therapy to improve neuropsychological and clinical outcomes in depression (Ketamine-ECT study)

et al. 2017

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BackgroundElectroconvulsive therapy (ECT) is the most effective acute treatment for severe depression, but there are concerns about its adverse cognitive effects. ECT may impair cognition through stimulation of glutamate receptors, and preliminary evidence has suggested that ketamine, a glutamate antagonist, may alleviate these effects. Ketamine has been shown to have a rapid, but temporary, antidepressant effect after a single infusion.ObjectiveTo determine the efficacy and safety of adjunctive low-dose ketamine to reduce cognitive impairments caused by ECT and, secondarily, to improve symptomatic outcome.DesignMulticentre, two-arm, parallel-group, patient-randomised, placebo-controlled superiority trial.SettingEleven ECT suites based in seven NHS trusts in the north of England.ParticipantsSeverely depressed hospitalised patients or outpatients who received ECT as part of their usual clinical care.InterventionsPatients were randomised to ketamine (0.5 mg/kg) or saline as an adjunct to their anaesthetic for their ECT course in a 1 : 1 ratio.Main outcome measuresThe primary outcome was delayed verbal recall on the Hopkins Verbal Learning Task – Revised (HVLT-R) after four ECT treatments (mid-ECT), analysed using a Gaussian repeated measures model. Secondary outcomes included autobiographical, working and visual memory and verbal fluency, symptoms and quality of life; assessments occurred at mid-ECT, end of treatment and 1 and 4 months after the last ECT. Neuropsychological function was compared with that of healthy control subjects and a functional near-infrared spectroscopy (fNIRS) substudy investigated prefrontal cortex function. A patient survey of study participation was carried out.ResultsSeventy-nine severely depressed patients were randomised to ketamine (0.5 mg/kg) or saline as an adjunct to their anaesthetic for their ECT course; the modified intention-to-treat sample included 70 patients. Compared with saline, adjunctive ketamine had no significant effect on HVLT-R delayed recall [treatment effect difference –0.43, 95% confidence interval (CI) –1.73 to 0.87], other neuropsychological outcomes, improvement in depression [difference in Montgomery–Åsberg Depression Rating Scale (MADRS) score of 0.44, 95% CI –1.03 to 1.91], the number of ECT treatments to remission (MADRS score of ≤ 10: 0.83, 95% CI –3.2 to 4.9), anxiety symptoms or quality of life. By the end of ECT treatment, 37% (saline 35%, ketamine 39%) of patients had remitted. Tolerability was similar in the two treatment arms; two patients had isolated transient psychological effects attributable to ketamine. Preliminary fNIRS analysis found that patients had blunted prefrontal cortical haemodynamic responses compared with control subjects during a verbal fluency task at baseline; this was further diminished at mid-ECT without modulation by ketamine. Greater haemodynamic responsivity to ECT appeared to be associated with a better clinical response. The majority of patients surveyed reported a positive experience of study participation.ConclusionsThe results of the study do not support the use of adjunctive ketamine in routine ECT treatment in the NHS. Although no evidence of benefit was found for ketamine, moderate benefits or harms cannot be excluded, as recruitment was < 50% of that planned, limiting the power of the clinical trial. Low numbers also meant that in the fNIRS substudy the effect of ketamine could not be assessed and the other findings must be viewed as preliminary. Included patients were younger than those not included and had only limited cognitive impairment with ECT, limiting generalisation to more cognitively compromised patients. fNIRS appeared to be a potentially feasible portable brain imaging technology in severely ill patients and further research is warranted to investigate its clinical utility.Trial registrationCurrent Controlled Trials ISRCTN14689382.FundingThis project was funded by the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research partnership.

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A Systematic Review and Meta-Analysis of Brief Versus Ultrabrief Right Unilateral Electroconvulsive Therapy for Depression

Cited by 173 publications

References 0 publications

The Ideal ECT Technique or the Ideal ECT Patient: What Should Be the Focus of Research?

The Ideal ECT Technique or the Ideal ECT Patient: What Should Be the Focus of Research?

Bitemporal Versus High-Dose Unilateral Twice-Weekly Electroconvulsive Therapy for Depression (EFFECT-Dep): A Pragmatic, Randomized, Non-Inferiority Trial

Randomised controlled trial of ketamine augmentation of electroconvulsive therapy to improve neuropsychological and clinical outcomes in depression (Ketamine-ECT study)

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