ECT in a patient with aortic aneurysm.

A patient with a history of corrected Type B dissecting aortic aneurysm and current Type III dissection of the aortic arch was successfully treated with electroconvulsive therapy (ECT) without complications. During ECT, intravenous nitroprusside and esmolol drips with arterial line monitoring were used to control the rise in blood pressure and heart rate. This case provides further evidence that ECT can be administered safely to patients with aortic aneurysm.

The impact of medication resistance and continuation pharmacotherapy on relapse following response to electroconvulsive therapy in major depression.

After clinical response to electroconvulsive therapy (ECT), 58 patients with major depressive disorder were followed for 1 year or until relapse. The rate of relapse was substantially higher in patients who had failed adequate antidepressant medication trials prior to ECT than in patients not determined to be medication resistant. Adequacy of post-ECT pharmacotherapy was only marginally related to likelihood of relapse. The subgroup of patients who appeared to benefit from adequate post-ECT pharmacotherapy were those who did not receive an adequate medication trial prior to ECT. The findings call into question the common practice of administering as continuation pharmacotherapy following ECT the same class of medications that patients had failed with during the acute episode prior to ECT. The findings also indicate that resistance to antidepressant medication is a strong predictor of relapse following response to ECT.

Effects of electrode placement on the efficacy of titrated, low-dose ECT.

This double-blind, random-assignment study contrasted the relative efficacy of bilateral and unilateral right ECT with a low-dose titration procedure. In 52 patients with primary major depressive disorder, bilateral ECT was markedly superior in short-term symptom reduction to unilateral right ECT. The two conditions did not differ in the duration of generalized seizures or in the number of treatments administered to achieve clinical response. The findings challenge the claim that the elicitation of generalized seizure is, in and of itself, sufficient for the antidepressant properties of ECT. Rather, a dose in excess of seizure threshold may contribute to the efficacy of ECT, particularly with a unilateral right electrode placement.

Continuation ECT in the management of relapses of major affective episodes.

Three cases are reported describing the use of continuation ECT. Continuation ECT consisted of six to twelve treatments for about 3 to 6 months after recovery from the index affective episode. Continuation ECT may be indicated in patients with a severe episode of illness, optimal acute response to ECT, and negative response to continuation drug therapy. In such patients, the mostly theoretical risks associated with the procedure may be outweighed by the dangers associated with early relapse.

Acute effects of ECT on cardiovascular functioning: relations to patient and treatment variables.

In 34 patients with primary, major depressive disorder, randomly assigned to bilateral or right unilateral ECT, heart rate (HR) and blood pressure (BP) were assessed prior and following seizure induction at every treatment. In contrast to prior reports, no cumulative pattern was observed in HR or BP changes as a function of treatment number. Generally, treatment variables, including ECT modality (bilateral vs. unilateral), anesthetic agent (methohexital vs. pentothal), and prior subconvulsive stimulation in a session, had no effects on the magnitude of peak postictal increases in HR or BP. The peak changes were also unrelated to the history of cardiac illness, remission of depressive symptomatology, patient seizure threshold and patient seizure duration. Pre-treatment HR was strongly predictive of peak postictal change in both HR and BP, while pretreatment BP was not. Patients with high pre-ECT HR had smaller peak postictal HR and BP increases. The findings suggested that low dosage, titrated ECT has HR and BP effects similar to traditional high dosage techniques, and that pre-treatment HR is the best predictor of these effects.

Seizure threshold in electroconvulsive therapy. Effects of sex, age, electrode placement, and number of treatments.

In a random-assignment trial to unilateral right and bilateral electrode placements, electroconvulsive therapy (ECT) stimulus intensity was titrated to just above seizure threshold for each of 52 depressed patients. Seizure threshold was quantified in units of charge. There was a 12-fold range in the minimum electrical intensity necessary to produce seizure. Sex, age, electrode placement, and the cumulative number of treatments were each associated with seizure threshold. Bilateral ECT had both a higher initial seizure threshold and a greater cumulative increase in seizure threshold compared with unilateral ECT. Clinical and research implications are discussed with respect to dosing strategies in ECT.

Serial dexamethasone suppression tests in initial suppressors and nonsuppressors treated with electroconvulsive therapy.

Four different methods of quantifying the 1-mg Dexamethasone Suppression Test (DST) were contrasted with serial testing in endogenous depressives receiving electroconvulsive therapy (ECT). Of three continuous measures in 38 patients with pretreatment DSTs, only the log-transformed value for plasma cortisol was normally distributed, indicating that it possessed superior psychometric properties. Pretreatment Hamilton Depression Rating Scores (HAM-D) correlated positively with pretreatment DST status, with a similar association noted between posttreatment DST status and HAM-D scores. There was no uniform effect of ECT on the DST. Although pretreatment nonsuppressors showed a trend toward decreased postdexamethasone cortisol values, initial suppressors (cutoff: 5 micrograms/dl) evidenced a significant increase in these values, and 35.3% of initial suppressors were nonsuppressors at final DST assessment. These trends were noted in the DST assessment done following the third ECT treatment, suggesting an effect of regression to the mean. The findings highlight the importance of following initial DST suppressors in studies of this type.

Studies of dosage, seizure threshold, and seizure duration in ECT.

Seizure threshold, defined as the minimal electrical dosage necessary to elicit adequate generalized seizure, was determined throughout the course of electroconvulsive therapy (ECT) in depressed patients randomly assigned to bilateral and right unilateral treatment, with brief pulse, constant current stimulation. In Study 1, it was found that seizure threshold may be more accurately measured using the unit of charge compared to the traditional unit of watt-second. In Study 2, it was found that seizure threshold was associated with seizure duration. Patients with high thresholds had shorter seizure durations. This indicated that the seizure threshold measure assesses in part functional neural activity. In Study 3, it was found that failure for seizure threshold to increase substantially over the course of ECT was associated with poor clinical outcome. In Study 4, it was found that electrical dosage at threshold was not related to magnitude of acute cognitive impairments. This suggested that the degree to which dosage exceeds threshold may be more strongly tied to adverse effects than the absolute dosage administered to patients. Implications of the data are discussed, particularly in relation to a hypothesized link between the anticonvulsant properties of ECT and its mechanism of therapeutic action.

Effects of ECT on the TRH stimulation test.

The prognostic value of the TRH stimulation test was evaluated in 23 inpatients with major depressive disorder before and after a trial of ECT. In contrast to previous reports, the peak TSH response to TRH was significantly decreased after treatment compared with before treatment. This effect was consistent across individuals and subgroups (responders/nonresponders; unilateral/bilateral ECT). The particular ECT technique used in the study may account for the discrepancies between these findings and those previously reported by other authors.

Effects of depression and ECT on anterograde memory.

This study investigated immediate and delayed recognition memory in depressed patients undergoing electroconvulsive therapy (ECT) and in matched, normal controls. At baseline, patients manifested a marked deficit in immediate memory (acquisition), but showed no deficit in delayed memory (retention). When retested 24-36 hr following the seventh ECT, patients showed reductions in both immediate and delayed memory performance. At retesting 4 days, on average, after the ECT course, immediate memory scores returned to baseline levels, but delayed memory performance remained impaired. The findings supported the classic claims that depression is associated with a deficit in the acquisition of information, whereas ECT has a more profound influence on the retention of information. This dissociative pattern could not be viewed as an artifact of task psychometric properties, nor of practice effects in control subjects.

Case report of lateralized affective states immediately after ECT.

Dysphoric states were observed in a patient immediately after right unilateral and bilateral ECT, while euphoric states followed left unilateral ECT, suggesting that disruption of lateralized neural mechanisms may have been involved in the pathophysiology of the affective states.

Cardiac arrest during ECT modified by beta-adrenergic blockade.

A hypertensive patient with a history of diabetes and ischemic heart disease was given propranolol before ECT and experienced cardiac arrest after subconvulsive electrical stimulation. The authors suggest exercising caution when combining beta-adrenergic blockade and ECT.

Anticonvulsant and antidepressant properties of electroconvulsive therapy: a proposed mechanism of action.

The efficacy of electroconvulsive therapy (ECT) in the treatment of affective disorders is well established. Despite its clinical utility, there is no generally accepted theory regarding its mode of action. Several lines of evidence indicate that ECT has significant anticonvulsant properties and results in decreased neural metabolic activity. We suggest that these effects are due to enhanced gamma-aminobutyric acid (GABA) transmission and that localized suppression of neural metabolic activity is associated with therapeutic response to ECT. An implication of this view is that ECT may be a useful adjunctive treatment in intractable epilepsy.