Ultrabrief ECT for Depression May Trump Standard ECT

Nancy A. Melville

July 22, 2015

Ultrabrief pulse stimulation electroconvulsive therapy (ECT) may trump standard ECT in the treatment of severe depression, new research suggests.

A meta-analysis conducted by investigators at the University of New South Wales, in Sydney, Australia, shows that ultrabrief ECT offers similar efficacy and fewer cognitive side effects.

"Based on these results, we would suggest that brief pulse ECT should be considered over ultrabrief pulse ECT in situations where urgency of response is paramount," the authors, led by Colleen Loo, MD, a professor of psychiatry and director of ECT at Wesley Hospital, in Sydney, write.

"The converse may be true for patients at higher risk for cognitive side effects but in whom an urgent clinical response is not essential," they add.

The study was published online July 21 in the Journal of Clinical Psychiatry.

Clinical Implications

Although regarded as a highly effective method for the treatment of depression in patients who fail to respond to other therapies, standard ECT has been associated with cognitive side effects, prompting different approaches, such as a switch from bitemporal to right unilateral (RUL) electrode placement, as well as the newer ultrabrief pulse width approach.

In the first meta-analysis to compare the brief pulse (standard) with ultrabrief pulse RUL ECT approaches, the investigators identified six studies involving 689 patients that met the analysis criteria and compared brief pulse with ultrabrief pulse RUL ECT.

The evaluation of efficacy, cognitive response, and remission outcomes showed brief pulse RUL ECT to be significantly more effective in the treatment of depression compared with ultrabrief pulse RUL ECT (P = .004), with improved results in mood ratings.

In addition, fewer brief pulse treatment sessions were necessary (8.7 vs 9.6; P < .001).

Ultrabrief pulse RUL ETC had a lower rate of remission (OR = 0.71; 95% CI, 0.51 - 0.99; P = .045). The pooled estimate suggested one additional remission for every 12.1 patients with brief pulse ECT compared with ultrabrief pulse ECT.

However, the brief pulse RUL ECT approach showed significantly greater cognitive side effects in all of the cognitive domains that were evaluated, including global cognition, anterograde learning and recall, and retrograde memory, compared with ultrabrief pulse (P < .01).

The authors noted that limitations of the analysis include not only the relatively small number of studies but also the fact that the two largest studies in the analysis were nonrandomized controlled trials, which left open the possibility of practitioner treatment or patient selection bias.

The efficacy differences between the two approaches were nonsignificant when the nonrandomized trials were removed.

Although the differences in efficacy are minimal, the differences in side effects are greater, Dr Loo told Medscape Medical News. "There is only a very small difference in efficacy between the two treatments," she said.

"I have treated many patients with both forms of ECT. The clinical differences in cognitive side effects are notable; there are clearly less with ultrabrief ECT."

For instance, "with brief pulse (standard) ECT, some patients have reported that past memories can be forgotten and in some cases do not return. This is much more unlikely with ultrabrief ECT," she said.

In addition, "the ultrabrief ECT takes a little longer to work for some patients."

On the basis of these results, clinicians may want to consider standard ECT for patients with more difficult-to-treat depression, Dr Loo said.

"The ultrabrief form of ECT should be considered for patients who are at high risk of cognitive side effects or for whom cognitive side effects are a primary concern. Patients with a very resistant form of depression that is difficult to treat may still require standard (brief pulse) ECT, which is slightly more effective."

Lifesavers

Psychiatrist Mark S. George, MD, a director of the Centre for Advanced Imaging Research and the Brain Stimulation Laboratory at the Medical University of South Carolina (MUSC), says he regularly uses both approaches and that his experience is not consistent with the findings.

"I would not say that ultrabrief pulse RUL is not quite as effective," he told Medscape Medical News.

"We don't really know that. I would say it is slower to act, requiring more sessions, [but] the ultimate efficacy, if patients and physicians were willing to wait, is likely similar."

Both approaches are exceptionally important in the management of treatment-refractory depression, he underscored.

"ECT of any type is a lifesaver and often works when patients have not responded to medications or transcranial magnetic stimulation [TMS]."

"Ultrabrief pulse RUL is a good treatment and is in fact our default treatment for patients here at MUSC," Dr George noted.

Because ultrabrief pulse RUL often takes longer to act, it typically is not used in situations of medical emergency, such as catatonia, he said. But for many other situations, the approach is suitable, he said.

"The best candidates for ultrabrief pulse RUL are typically patients who have tried and failed medications and TMS, who are relatively stable (without catatonia), and who are concerned about potential cognitive side effects, such as the elderly or those patients working with cognitively demanding jobs."

The study received no funding. The authors have disclosed no relevant financial relationships. Dr George is an unpaid consultant for numerous TMS manufacturers and for Mesta, an ECT manufacturer. He has no equity ownership in any device or pharmaceutical company.

J Clin Psychiatry. Published online July 21, 2015. Abstract

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