ReviewECT efficacy and treatment course: A systematic review and meta-analysis of twice vs thrice weekly schedules
Introduction
Electroconvulsive therapy (ECT) has been used in the treatment of severe mental disorders for approximately eight decades. The efficacy of ECT for severely depressed patients has been well established (UK ECT Review Group, 2003, Kho et al., 2003), however, there remains a lack of clear consensus on the optimal frequency of treatment for individual patients.
Frequency of treatment has important implications for resource utilisation, especially in settings where the availability of operator, anaesthetist or theatre time is a limiting factor. Demographic ageing in many populations can compound these problems, as treatment rates for elderly people may be three or four times greater than for younger people (Eranti and McLoughlin, 2003, Rapoport et al., 2006; Melding, 2006, Chanpattana, 2007).
Meta-analysis of randomised controlled trials examining efficacy of differing ECT schedules in patients with major depression was first attempted in 2003 and showed no difference between twice a week and thrice a week, or between once a week and three times a week protocols (UK ECT Review Group, 2003). More recent reviews on this topic have concluded that evidence exists to suggest that twice-weekly ECT may provide a better balance between therapeutic outcome and cognitive adverse effects (Loo et al., 2010, Gangadhar and Thirthalli, 2010). The lack of clear consensus on optimal ECT frequency has led to recommendations that vary between twice and thrice weekly protocols (APA, 2001, Scott, 2005, Victorian Government, 2009, NSW Department of Health, 2010). So far there has been no quantitative assessment of the effect of treatment frequency on other patient- and service-related outcomes of differing ECT frequencies such as duration of treatment and cognitive function. We therefore decided to re-evaluate randomised controlled trials on this topic with a view to addressing associations between ECT frequency and depression scores, duration of treatment, number of ECTs, remission rates, length of hospital stay, cognitive impairments, and speed of response.
Section snippets
Search strategy
Comparative data were sought for the improvement of depression scores and level of cognitive impairment over a treatment course. Other outcomes of interest included number of ECT treatments given, the duration of ECT treatment, remission rates, length of hospital stay, and speed of response. Computerised literature searches were performed using the MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EBSCOhost, Embase, Psycinfo, Web of Knowledge, Scopus and Cochrane
Characteristics of included studies
Five thousand, six hundred and five records were identified from the electronic database search and nine papers were deemed relevant for inclusion in this review (Stromgren, 1975, Stromgren et al., 1976, McAllister et al., 1987, Kellner et al., 1992, Gangadhar et al., 1993, Lerer et al., 1995, Vieweg and Shawcross, 1998, Shapira et al., 1998, Janakiramaiah et al., 1998). Five of the final nine articles compared administration of twice weekly and thrice weekly ECT (McAllister et al., 1987,
Discussion
In accordance with previous work there appears to be no significant difference between twice and thrice weekly ECT in terms of antidepressant effect. We did however find a statistically significant advantage for thrice weekly ECT over once weekly ECT with a large effect size. In addition our findings suggest a small increase in days under treatment that accounts for the absence of a statistically significant reduction in real ECTs for biweekly treatment. Remission rates as defined by targets
Role of funding source
Funding for this study was provided by a grant from Queensland Health Mental Health Directorate (MHD); the MHD had no further role in the study design; in the collection, in the analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgement
We would like to thank Associate Professor David Crompton and Dr Saibal Guha for providing advice on the conceptualization of this project.
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