Electroconvulsive therapy remains one of the most effective treatments for severe depression, but new UNSW research shows ultra-brief pulse stimulation is almost as effective as standard ECT, with far fewer cognitive side effects.
The study, published today in the Journal of Clinical Psychiatry, is the first systematic review to examine the effectiveness and cognitive effects of standard ECT treatment, brief pulse stimulation, versus the newer treatment, known as ultra-brief pulse right unilateral (RUL) ECT.
It comes after previous trials had shown conflicting results. The latest study reviewed six international ECT studies comprising 689 patients with a median age of 50 years old.
It found while standard ECT was slightly more effective for treating depression and required one less treatment, this came at a cost with significantly more cognitive side effects.
“This new treatment, which is slowly coming into clinical practice in Australia, is one of the most significant developments in the clinical treatment of severe depression in the past two decades,” according to UNSW Professor of Psychiatry Colleen Loo.
“Our analysis of the existing trial data showed that ultra-brief stimulation significantly lessened the potential for the destruction of memories formed prior to ECT, reduced the difficulty of recalling and learning new information after ECT and was almost as effective as the standard ECT treatment,” Professor Loo said.
ECT delivers a finely controlled electric current to the brain’s prefrontal cortex, an area that is underactive in people with depression. The current is delivered via electrodes on a patient’s scalp while the patient is under general anaesthesia.
Ultra-brief stimulation delivers staccato pulses of electricity, with each pulse on for only a very short time. As the pulses are so short, the stimulation of brain tissue is reduced by a third.
It is estimated that up to 10,000 Australians with severe depression and who have not responded to first line treatments, such as medication, could benefit from the new treatment. Less than half of Australia’s hospitals currently offer ultra-brief stimulation.
Professor Loo, who is also director of ECT at Sydney’s Wesley Hospital and a researcher with the Black Dog Institute, said she hopes the study will result in an improved uptake of the new treatment for people with severe depression.
“We are still working hard to change the broader medical profession’s and general public’s perception of ECT, which has struggled to shake off the tarnished image given to it by popular movies such as the 1975 film ‘One Flew Over the Cuckoo’s Nest’,” Professor Loo said.
While the benefits of ultra-brief stimulation are significant, the study authors concluded that standard ECT treatment should still be considered over the new treatment, where urgency of response was paramount.
The study only analysed the short-term effectiveness and side effects of ultra-brief stimulation. Studies into the long-term effects of ECT are ongoing. The study was conducted in partnership with the Institute of Mental Health, Singapore.
About this depression research
Source: Dan Wheelahan – University of New South Wales Image Credit: The image is in the public domain Original Research:Abstract for “A Systematic Review and Meta-Analysis of Brief Versus Ultrabrief Right Unilateral Electroconvulsive Therapy for Depression” by Phern-Chern Tor, MBBS, DFD(CAW), MMed(Psych); Alison Bautovich, MBBS; Min-Jung Wang, MSC; Donel Martin, MClinNeuro, PhD; Samuel B. Harvey, MBBS, MRCGP, MRCPsych, FRANZCP, PhD; and Colleen Loo, MBBS, FRANZCP, MD in Journal of Clinical Psychiatry. Published online July 21 2015 doi:10.4088/JCP.14r09145
A Systematic Review and Meta-Analysis of Brief Versus Ultrabrief Right Unilateral Electroconvulsive Therapy for Depression
Objective: Electroconvulsive therapy (ECT) is an effective depression treatment, but it has potential cognitive side effects. Ultrabrief pulse (UBP) right unilateral (RUL) ECT is an increasingly used treatment option that can potentially combine efficacy with lesser cognitive side effects. However, current trials are underpowered or have conflicting results. A systematic review and meta-analysis was conducted to evaluate the relative efficacy and cognitive effects of brief pulse (BP) and UBP RUL ECT.
Data Sources: MEDLINE, EMBASE, PsycINFO, CENTRAL, DARE, and the International Clinical Trials Registry Platform were searched with the search terms ECT, electroconvulsive therapy, electroconvulsive shock, electroconvulsive shock therapy, electrical stimulation, electroconvulsive combined with brief, ultra*, pulse, and trial in English, all fields including title, abstract, subject heading, and full text up to June 20, 2013, for studies comparing BP and UBP RUL ECT in depressed patients that reported formalized mood ratings for depression.
Study Selection: Six studies met the inclusion criteria, comprising a total of 689 patients.
Data Extraction: Efficacy, cognitive, response, and remission outcomes were extracted from each publication or obtained directly from authors.
Results: BP RUL ECT was significantly more efficacious in treating depression than UBP RUL ECT (standardized mean difference = 0.25; 95% CI, 0.08–0.41; P = .004) but showed significantly more cognitive side effects in all cognitive domains examined (global cognition, anterograde learning and recall, retrograde memory) (P < .01). The mean number of treatment sessions given was 8.7 for BP ECT and 9.6 for UBP ECT (P < .001). UBP had a lower remission rate (OR = 0.71; 95% CI, 0.51–0.99; P = .045), with a number needed to treat of 12.1.
Conclusions: BP compared with UBP RUL ECT was slightly more efficacious in treating depression and required fewer treatment sessions, but led to greater cognitive side effects. The decision of whether to use BP or UBP RUL ECT should be made on an individual patient basis and should be based on a careful weighing of the relative priorities of efficacy versus minimization of cognitive impairment.
“A Systematic Review and Meta-Analysis of Brief Versus Ultrabrief Right Unilateral Electroconvulsive Therapy for Depression” by Phern-Chern Tor, MBBS, DFD(CAW), MMed(Psych); Alison Bautovich, MBBS; Min-Jung Wang, MSC; Donel Martin, MClinNeuro, PhD; Samuel B. Harvey, MBBS, MRCGP, MRCPsych, FRANZCP, PhD; and Colleen Loo, MBBS, FRANZCP, MD in Journal of Clinical Psychiatry. Published online July 21 2015 doi:10.4088/JCP.14r09145