2007 Effect Vienna Loo

8/8/2019 2007 Effect Vienna Loo

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Ultrabrief PulsewidthRUL ECT

Colleen Loo

Assoc Prof, School of PsychiatrySt George Hospital Clinical School/ University of NSW

& Black Dog Institute & Northside Clinic

Sydney, Australia


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Conventional ECT

Variations in Electrical Doseand Electrode Placement

Less Efficacy More Efficacy

Less Side Effects More Side Effects

Unilateral ECT Bilateral ECT

Low Dose High Dose


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Pulse

width

Current

amplitude

Frequency pulses / second

Train duration (seconds)


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Pulse Width

Typical ECT pulse : 0.5 1.5 ms

Chronaxie of neurons : 0.1-0.2 ms

seizure threshold with shorter pulse width< 0.5 ms


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Ultrabrief pulse ECTSackeim, 2004

0.3 ms

RUL 6 T

Randomised 1.5 ms

0.3 msBL 2.5 T

1.5 ms


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Comparison RUL-UB (6xST)

with RUL (1.0ms, 3.5xST)Retrospective comparison: RUL-UB from Dec 2005 - 2006

RUL from 2003- Nov 2005

N=30 per group

Matched for age & gender

Compared clinical characteristics treatment

resistance etcFile review Likert scores re improvement (0-3)

File review clinical impression of response

(yes / no)


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Titration and Treatment Schedule for

Ultra Brief Pulse (0.3mSec pulse width)

ECTA Spectrum SQ 5000 (RUL ONLY)

Titration Treatment (6 X Threshold RUL)Charge

Stimulus 120Hz0.3 mSec 9.6 mC 1.0 sec800 mAmps

Charge %> ST

40 Hz0.3 mSec 57.6 mC 500%3.0 sec800 mAmps

Stimulus 220 Hz0.3 mSec 19.2 mC 2.0 sec800 mAmps

50 Hz0.3 mSec 120 mC 525%5.0 sec800 mAmps


80 Hz0.3 mSec 230.4 mC 500%6.0 sec800mAmps

Stimulus 420 Hz0.3 mSec 76.8 mC 8.0 sec

800 mAmps

120 Hz0.3 mSec 460.8 mC 500%8.0 sec800 mAmps



Stimulus 680 Hz0.3 mSec 307.2 mC 8.0 sec

800mAmps



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Outcomes of RUL-UB

Group

Average no of ECT: 11.8

14/30 switched to bilateral ECT

For completers:

Mean reduction MADRS 45%

17/30 response (MADRS < 50% baseline)

4/30 remission (MADRS < 10)


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Cognitive Assessment

(Measure)Time of Testing Mean SD % Change

Paired t-test

(df = 24)p-value

Visual Learning

(RF Recall Trial)

Baseline

6 Treatments

17.9

19.0

8.9

8.5

5.7 0.75 0.46

Visual Memory

(RF Delayed Recall trial)

Baseline

6 Treatments

18.6

18.7

9.7

7.0

0.5 0.08 0.93

Verbal learning

(RAVLT Trial 5 -Trial 1)

Baseline

6 Treatments

5.0

3.8

2.5

2.1

-11.2 2.99 0.006

Verbal Retention

(RAVLT Trial 6 Recall -Delayed Recall)

Baseline

6 Treatments

-0.1

-0.5

1.6

1.6

3.6 1.12 0.27

Verbal Fluency (letters)

(COWAT)

Baseline

6 Treatments

41.5

32.5

11.7

9.0

-27.7 3.56 0.002

Verbal Fluency (categories)

(COWAT)

Baseline

6 Treatments

19.3

15.3

3.5

6.2

-26.1 2.71 0.013

Attention

(WAIS-R Digits Forward)

Baseline

6 Treatments

8.1

7.7

2.7

2.6

-5.2 1.06 0.30

Attention

(Stroop Test - Interference

ratio)

Baseline

6 Treatments

2.0

1.6

0.7

0.6

25 1.96 0.07

Psychomotor Function

(Stroop Test - median RT)

Baseline

6 Treatments

16.8

17.3

5.8

4.2

-2.9 -0.43 0.67

Retrograde Memory

(AMI)

Baseline

Six Treatments

11.9

11.7

1.3

1.3

-1.7 0.70 0.49

Cognitive Assessments at Baseline and after 6 Treatments of RUL-UB ECT (n=23)


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Demographic and Clinical Characteristics of the 2 Patient Groups:

RUL-UB (n=30) & RUL (n=30)

RUL-UB RUL t-test Chi df p

Age : Mean (SD) 44.3 (12.8) 45.3 (12.0) 0.26 58 0.80

Diagnosis: MDD/Bipolar 17/13 27/3 8.52 1


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Retrospective comparison :ECT treatment efficacy, length and parameters (n=60)

RUL-UB RUL t-

test

chi df p

Likert Mood Ratings: Mean (SD) 1.6 (1.2) 1.2 (1.1) 1.07 29 0.29

Response to RUL/RUL-UB 16/30 15/30 0.07 1 0.80

Number of treatment sessions *: Mean

(SD)

11.8 (3.8) 8.8 (4.3) 2.05 29 0.050

Patients who switched to Bilateral ECT 14/30 15/30 0.07 1 0.80

Initial Seizure Threshold (mC): Mean

(SD)

27.5 (14.4) 77.8 (42.1) 5.96 29


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The Northside Clinic

ECT TrialEffectiveness trial (non randomised): Bitemporal ECT @ 1.5 ST

Bifrontal ECT @ 1.5 ST

RUL ECT @ 5 ST

RUL-UB ECT @ 6 ST

Prospective, single blind ratings of efficacy

(weekly MADRS) & cognitive function


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The Northside Clinic ECT Trial

Cognitive Tests baseline, after 6 ECT, end

course:

Digit Span (attention)

Rey Auditory Verbal Learning Test (verbal

memory)

Rey figure (non-verbal memory)

Controlled Oral Word Association Test (frontal

function)

STROOP (attention, frontal function)

Autobiographical Memory Interview (retrograde

memory)


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Northside Clinic ECT Trial

DSM-IV Major Depressive Episode

MADRS 25

No recent drug/alcohol abuse/ ECT

MMSE 20

ECT 3 x/ week

Anaesthesia: thiopentone &

suxamethonium


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Rey Complex Figure Drawing- % Recall

Time p = .125, ECT p = .449, Time X ECT p = .064

Pre ECT Po Se ion ECT

Mean%

eca

ll--

B =

=

B =


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MADRS Scores

Time p


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Conclusions

RUL UB ECT @ 6 x ST:

Promising cognitive outcomes

Efficacy reduced?

Require more treatments? Similar in efficacy to RUL @ 3 x ST, with

fewer cognitive side effects?

Lesser efficacy than RUL @ 6 x ST, markedly

fewer side effects


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Acknowledgements

The Northside Clinic ECTTrial:

Co-Investigator: Dr Bill Lyndon

Research staff: Sarah Campbell

Magdalena Pusok

Patrick Sheehan

Melissa Pigot

ECT service: Dianne Hollings (ECT coordinator)

ECT psychiatrists

Patients

Documents

2007 Effect Vienna Loo