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Brief vs. ultrabrief pulse ECT: focus on seizure quality

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Abstract

The effect of electroconvulsive therapy (ECT) performed with ultrabrief pulse (UBP) stimulation has been found inferior to brief pulse (BP) ECT in various studies. We reinvestigated this issue using a new dosing strategy that is based on seizure quality instead of seizure threshold. There is a long history of studies associating ictal characteristics of ECT with the clinical outcome. Accordingly, we used the clinical status of the patient and the quality of the prior seizure to determine the dosage for the upcoming treatment—referred to as Clinical and Seizure Based Stimulation (CASBAS). This approach aims at continuously providing high-quality seizures to optimize the outcome. While this dosing strategy was applied in our department, the pulse width was changed for a period of time from BP to UBP. It was hypothesized that the procedure would: (1) maintain seizure quality and clinical outcome under both conditions and would; and (2) compensate the lesser clinical efficacy of UBP by an increase in stimulus intensity. 245 patients received an ECT course according to the dosing strategy described, 162 with brief pulse (BP) and 83 with ultrabrief pulse ECT (UBP). In a retrospective evaluation, seizure quality and clinical outcome (available in a 20% subgroup of patients) did not differ between both groups in most of the examined parameters, while stimulus intensity was found to be significantly higher in the UBP group. As hypothesized, UBP was less efficient than BP in providing comparable ictal quality and clinical outcome. In a first test of concept the dosing strategy CASBAS seemed suitable to continuously adjust the stimulus intensity in ECT and maintain the seizure quality.

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References

  1. Spaans H-P, Verwijk E, Comijs HC et al (2013) Efficacy and cognitive side effects after brief pulse and ultrabrief pulse right unilateral electroconvulsive therapy for major depression: a randomized, double-blind, controlled study. J Clin Psychiatry 74:e1029–e1036. https://doi.org/10.4088/JCP.13m08538

    Article  PubMed  Google Scholar 

  2. Loo CK, Garfield JBB, Katalinic N et al (2013) Speed of response in ultrabrief and brief pulse width right unilateral ECT. Int J Neuropsychopharmacol 16:755–761. https://doi.org/10.1017/S1461145712000806

    Article  CAS  PubMed  Google Scholar 

  3. Spaans H-P, Kho H, Verwijk K E, et al (2013) Efficacy of ultrabrief pulse electroconvulsive therapy for depression: a systematic review. J Affect Disord 150:720–726. https://doi.org/10.1016/j.jad.2013.05.072

    Article  PubMed  Google Scholar 

  4. Sackeim HA, Prudic J, Nobler MS et al (2008) Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. Brain Stimul 1:71–83. https://doi.org/10.1016/j.brs.2008.03.001

    Article  PubMed  PubMed Central  Google Scholar 

  5. Loo CK, Sainsbury K, Sheehan P, Lyndon B (2008) A comparison of RUL ultrabrief pulse (0.3 ms) ECT and standard RUL ECT. Int J Neuropsychopharmacol 11:883–890

    PubMed  Google Scholar 

  6. Abrams R (2002) Stimulus titration and ECT dosing. J ECT 18:3–9

    Article  Google Scholar 

  7. Swartz CM (2001) Stimulus dosing in electroconvulsive therapy and the threshold multiple method. J ECT 17:87–90

    Article  CAS  Google Scholar 

  8. Mayur P (2006) Ictal electroencephalographic characteristics during electroconvulsive therapy: a review of determination and clinical relevance. J ECT 22:213–217. https://doi.org/10.1097/01.yct.0000235922.14623.39

    Article  PubMed  Google Scholar 

  9. Minelli A, Abate M, Zampieri E et al (2016) Seizure adequacy markers and the prediction of electroconvulsive therapy response. J ECT 32:88–92. https://doi.org/10.1097/YCT.0000000000000274

    Article  PubMed  Google Scholar 

  10. Perera TD, Luber B, Nobler MS et al (2004) Seizure expression during electroconvulsive therapy: relationships with clinical outcome and cognitive side effects. Neuropsychopharmacology 29:813–825. https://doi.org/10.1038/sj.npp.1300377

    Article  PubMed  Google Scholar 

  11. Folkerts H (1996) The ictal electroencephalogram as a marker for the efficacy of electroconvulsive therapy. Eur Arch Psychiatry Clin Neurosci 246:155–164

    Article  CAS  Google Scholar 

  12. Azuma H, Fujita A, Sato K et al (2007) Postictal suppression correlates with therapeutic efficacy for depression in bilateral sine and pulse wave electroconvulsive therapy. Psychiatry Clin Neurosci 61:168–173. https://doi.org/10.1111/j.1440-1819.2007.01632.x

    Article  PubMed  Google Scholar 

  13. Krystal AD, Weiner RD, Coffey CE (1995) The ictal EEG as a marker of adequate stimulus intensity with unilateral ECT. J Neuropsychiatry Clin Neurosci 7:295–303. https://doi.org/10.1176/jnp.7.3.295

    Article  CAS  PubMed  Google Scholar 

  14. Swartz CM (2000) Physiological response to ECT stimulus dose. Psychiatry Res 97:229–235. https://doi.org/10.1016/S0165-1781(00)00234-1

    Article  CAS  PubMed  Google Scholar 

  15. Haeck M, Gillmann B, Janouschek H, Grözinger M (2011) Electroconvulsive therapy can benefit from controlled hyperventilation using a laryngeal mask. Eur Arch Psychiatry Clin Neurosci 261:172–176. https://doi.org/10.1007/s00406-011-0240-4

    Article  Google Scholar 

  16. Nobler MS, Sackeim HA, Solomou M et al (1993) EEG manifestations during ECT: effects of electrode placement and stimulus intensity. Biol Psychiatry 34:321–330. https://doi.org/10.1016/0006-3223(93)90089-V

    Article  CAS  PubMed  Google Scholar 

  17. Kranaster L, Kammerer-Ciernioch J, Hoyer C, Sartorius A (2011) Clinically favourable effects of ketamine as an anaesthetic for electroconvulsive therapy: a retrospective study. Eur Arch Psychiatry Clin Neurosci 261:575–582. https://doi.org/10.1007/s00406-011-0205-7

    Article  PubMed  Google Scholar 

  18. Hoyer C, Kranaster L, Janke C, Sartorius A (2014) Impact of the anesthetic agents ketamine, etomidate, thiopental, and propofol on seizure parameters and seizure quality in electroconvulsive therapy: a retrospective study. Eur Arch Psychiatry Clin Neurosci 264:255–261. https://doi.org/10.1007/s00406-013-0420-5

    Article  PubMed  Google Scholar 

  19. Sackeim HA (1999) The anticonvulsant hypothesis of the mechanisms of action of ECT: current status. J ECT 15:5–26. https://doi.org/10.1097/00124509-199903000-00003

    Article  CAS  PubMed  Google Scholar 

  20. Krystal AD, Coffey CE, Weiner RD, Holsinger T (1998) Changes in seizure threshold over the course of electroconvulsive therapy affect therapeutic response and are detected by Ictal EEG ratings. J Neuropsychiatry Clin Neurosci 10:178–186. https://doi.org/10.1176/jnp.10.2.178

    Article  CAS  PubMed  Google Scholar 

  21. Loh N, Nickl-Jockschat T, Sheldrick AJ, Grözinger M (2013) Accessibility, standards and challenges of electroconvulsive therapy in Western industrialized countries: a German example. World J Biol Psychiatry 14:432–440. https://doi.org/10.3109/15622975.2012.665176

    Article  PubMed  Google Scholar 

  22. Kranaster L, Hoyer C, Janke C, Sartorius A (2013) Bispectral index monitoring and seizure quality optimization in electroconvulsive therapy. Pharmacopsychiatry 46:147–150. https://doi.org/10.1055/s-0032-1331748

    Article  CAS  PubMed  Google Scholar 

  23. Weiner RD, Coffey CE, Krystal AD (1991) The monitoring and management of electrically induced seizures. Psychiatr Clin N Am 14:845–869

    Article  CAS  Google Scholar 

  24. Azuma H, Fujita A, Otsuki K, Nakano Y (2007) Ictal electroencephalographic correlates of posttreatment neuropsychological changes in electroconvulsive therapy: a hypothesis-generation study. J ECT 23:163–168

    Article  Google Scholar 

  25. Ranganath RD, Gangadhar BN, Tomar M et al (2003) ECT and heart rate changes: an alternative to EEG monitoring for seizure confirmation during modified ECT. Ger J Psychiarty 3:60–63

    Google Scholar 

  26. Krystal AD, Holsinger T, Weiner RD, Coffey CE (2000) Prediction of the utility of a switch from unilateral to bilateral ECT in the elderly using treatment 2 ictal EEG indices. J ECT 16:327–337

    Article  CAS  Google Scholar 

  27. Swartz CM, Nelson AI (2005) Rational electroconvulsive therapy electrode placement. Psychiatry (Edgmont) 2:37–43

    Google Scholar 

  28. Loo CK, Katalinic N, Smith DJ et al (2014) A randomized controlled trial of brief and ultrabrief pulse right unilateral electroconvulsive therapy. Int J Neuropsychopharmacol 18:1–8. https://doi.org/10.1093/ijnp/pyu045

    Article  Google Scholar 

  29. Loo C, Sheehan P, Pigot M, Lyndon W (2007) A report on mood and cognitive outcomes with right unilateral pulse width (0.3 ms) ECT and retrospective comparison with standard pulse width right unilateral ECT. J Affect Disord 103:277–281. https://doi.org/10.1016/j.jad.2007.06.012

    Article  PubMed  Google Scholar 

  30. Tor P, Bautovich A, Wang M-J et al (2015) A systematic review and meta-analysis of brief versus ultrabrief right unilateral electroconvulsive therapy for depression. J Clin Psychiatry 76:e1092–e1098. https://doi.org/10.4088/JCP.14r09145

    Article  PubMed  Google Scholar 

  31. Janouschek H, Nickl-Jockschat T, Haeck M et al (2013) Comparison of methohexital and etomidate as anesthetic agents for electroconvulsive therapy in affective and psychotic disorders. J Psychiatr Res 47:686–693. https://doi.org/10.1016/j.jpsychires.2012.12.019

    Article  CAS  PubMed  Google Scholar 

  32. Cung K-F (2002) Relationships between seizure duration and seizure threshold and stimulus dosage at electroconvulsive therapy: implications for electroconvulsive therapy practice. Psychiatry Clin Neurosci 56:521–526. https://doi.org/10.1046/j.1440-1819.2002.01048.x

    Article  Google Scholar 

  33. Sackeim HA, Decina P, Portnoy S et al (1987) Studies of dosage, seizure threshold, and seizure duration in ECT. Biol Psychiatry 22:249–268

    Article  CAS  Google Scholar 

  34. Frey R, Heiden A, Scharfetter J et al (2001) Inverse relation between stimulus intensity and seizure duration: implications for ECT procedure. J ECT 17:102–108

    Article  CAS  Google Scholar 

  35. Saravanan ESM, Gangadhar BN, Janakiramaiah N et al (2002) Does higher cardiovascular response to ECT predict early antidepressant effect? J Affect Disord 69:101–108. https://doi.org/10.1016/S0165-0327(00)00383-9

    Article  CAS  PubMed  Google Scholar 

  36. Nobler MS, Luber B, Ph D et al (2000) Quantitative EEG during seizures induced by electroconvulsive therapy: relations to treatment modality and clinical features. I. Global analyses. J ECT 16:211–228

    Article  CAS  Google Scholar 

  37. Chanpattana W, Buppanharun W, Raksakietisak S, Somchai Chakrabhand ML (2000) Seizure threshold rise during electroconvulsive therapy in schizophrenic patients. Psychiatry Res 96:31–40. https://doi.org/10.1016/S0165-1781(00)00186-4

    Article  CAS  PubMed  Google Scholar 

  38. Chanpattana W, Chakrabhand MLS, Buppanharun W, Sackeim HA (2000) Effects of stimulus intensity on the efficacy of bilateral ECT in schizophrenia: a preliminary study. Biol Psychiatry 48:222–228. https://doi.org/10.1016/S0006-3223(00)00830-1

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

We thank the ECT-Workshop-Group of the German-speaking countries, the Netherlands and Belgium for the critical discussion and the helpful comments and suggestions. Special thanks go to Dr. Manfred Klaas for revising the manuscript.

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Authors and Affiliations

  1. Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, Uniklinik Aachen, RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany

    Isabelle Brunner & Michael Grözinger

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  1. Isabelle Brunner
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  2. Michael Grözinger
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Correspondence to Isabelle Brunner.

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Ethical standards

The retrospective analysis was approved by the Ethics Committee at the medical faculty of RWTH Aachen University. All persons gave their informed consent prior to their ECT treatment and only data collected by default was included in the study.

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On behalf of all authors, the corresponding author states that there is no conflict of interest.

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Brunner, I., Grözinger, M. Brief vs. ultrabrief pulse ECT: focus on seizure quality. Eur Arch Psychiatry Clin Neurosci 268, 831–838 (2018). https://doi.org/10.1007/s00406-018-0925-z

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