Augmentation Strategies in Electroconvulsive Therapy

Abstract

Electroconvulsive therapy (ECT) is a highly effective treatment, but strategies to enhance therapeutic outcomes are occasionally needed. This review examines the evidence for approaches used for enhancing seizure production: hyperventilation, pretreatment with xanthines, and use of remifentanil or ketamine in ECT anesthesia. Hyperventilation may be a useful strategy to enhance seizure production, but its effects on ECT outcomes have not been systematically studied and require further research. Pretreatment with caffeine, theophylline or aminophylline (xanthines) prolongs the duration of ECT seizures but has not been clearly shown in controlled trials to increase efficacy. Caution is also warranted because their use may be associated with significant adverse effects. There are case reports of the usefulness of remifentanil in assisting seizure induction by reducing the dose of barbiturate anesthetic required, but there are no controlled data on whether it independently enhances efficacy outcomes. Preliminary evidence suggests that ketamine and ECT may have synergistic antidepressant effects, although this needs to be further examined in randomized controlled trials.

A systematic review and meta-analysis of randomized controlled trials of adjunctive ketamine in electroconvulsive therapy: Efficacy and tolerability

“…This has in turn stimulated interest in augmentation strategies in order to improve clinical response to ECT. Several augmentation strategies have been employed (Loo et al, 2010), including hyperventilation, caffeine, and remifentanil.…”

Bispectral Index Monitoring and Seizure Quality Optimization in Electroconvulsive Therapy

“…On the basis of these parameters, we defi ned a seizure as "ideal" when it was of adequate duration (criterion 1, see above) and fulfi lled all other criteria. We defi ned "nearly ideal", when the seizure had suffi cient duration (criterion 1) and fulfi lled 3 out of the 4 other criteria (2)(3)(4)(5). We defi ned "probably insuffi cient" as a seizure that either did not have the necessary duration or did not fulfi ll at least 3 of the other seizure parameters.…”

Combined electrophysiological and biosensor approaches to study purinergic regulation of epileptiform activity in cortical tissue

“…Furthermore, this adenosine tone can also be reduced by hypocapnia, which promotes seizure activity in hippocampal slices (Dulla et al, 2005). The fact that hyperventilation-induced hypocapnia is used to provoke seizures as a diagnostic test (Mendez and Brenner, 2006) and enhance electroconvulsive seizures, as are A1 receptor antagonists such as caffeine, theophylline and aminophylline (Loo et al, 2010), strongly suggests an important tonic inhibitory role for endogenous adenosine in the regulation of human seizures. Moreover, successful attempts to terminate human epileptic seizures, even after their initiation, have been made using 5 % CO2 inhalation (Tolner et al, 2011).…”