Effects of electroconvulsive therapy for depression on health

related quality of life

Adam Kavanagh

Acknowledgements

• Prof. Declan McLoughlin

• Dr. Maria Semkovska, Dr. Ross Dunne, Dr. Martha Noone, Dr. Erik Kolshus, Ana Jelovac, Sinead Lambe, Mary Carton

• Shane McCarron, Ger Ryan, Lucy Kiely

Presentation outline

• Depression

• Electroconvulsive therapy

• Aim

• Methodology

• Results

Depression

• 7% - 12% for men

• 20% - 25% for women• 4th highest contributor to total burden of disease

• 2nd leading cause of disability by 2020

Low mood or Anhedonia

WeightSleepConcentrationPsychomotor agitation/ retardationFatigueWorthlessness/ guiltSuicidal thoughts

The symptoms cause clinically significant impairment in functioning

Electroconvulsive therapy

Kavanagh & McLoughlin 2009

Aim

• The aim of this study was to compare the

effects of 1.5 × ST bitemporal and high dose (6

× ST) RUL ECT administered twice weekly on

Health related quality of life (HRQOL)

Methodology

• EFFECT-DEP TRIAL (ISRCTN23577151)

– Design

– Location

– Inclusion/ Exclusion

– Randomization

– Primary outcome

– Power

SF-36• A generic outcome measure • Subjectively rated• Only 36 questions• 8-scale profile of functional health and well-being• Psychometrically-based physical and mental health

summary measures• Normative data • Sensitive to change • Most frequently used patient rated outcome

measure used in clinical trials (Scoggins & Patrick 2009)

Results

Results 

High-dose RUL

Mean (SD)

Bitemporal

Mean (SD)

t-test (d.f.) χ²-test (d.f.) P

Demographic 

details

Age 56.7 (15.0) 59.1 (13.8) -1.173 (98) P = 0.244

Female 29 (58%) 31 (62%) 0.167 (1) P = 0.683

 

Clinical details

Baseline HDRS 30.3 (6.8) 29.3 (7.0) 0.720 (98) P = 0.473

Baseline BDI II 32.1 (11.9) 37.2 (13.6) -1.515 (56) P = 0.135

Psychotic 8 (16%) 6 (12%) 0.500 (1) P = 0.479

Treatment 

resistant 

25 (50%) 30 (60%) 0.646 (1) P = 0.421

Previous ECT 22 (44%) 20 (40%) 0.041 (1) P = 0.839

Pre-treatment N (RUL = 36, Bi = 32), 6 months N (RUL = 26, bi = 28), 

Completed both assessments (RUL = 21, Bi = 22)

Pre-treatment N (RUL = 36, Bi = 32), 6 months N (RUL = 26, bi = 28), 

Completed both assessments (RUL = 21, Bi = 22)

HRQOL 6 months after ECT for severe depression

compared to “normal” population

Predicting HRQOL 6 months after ECT for severe depression

Linear model

MCS score =

Treatment parameters (Laterality, dose, seizure duration)

+ Patient characteristics (Gender, age)

+ Clinical details (Medications, resistance, remission status,

cognitive functioning)

Remission status at EOT

Summary

• Depression significantly impacts HRQOL• ECT is associated with improvements in

subjectively assessed HRQOL• High dose RUL ECT is as effective as standard

bitemporal ECT• Persistent deficits 6 months after treatment• Remission status at EOT explained persistent

deficits

Strengths & limitations

• Strengths– Randomized design– Large sample size– New information about HDRUL ECT– Generalizable results– No difference between participants that completed

assessments and those that did not– Robust outcomes measure– Robust data analysis approach

• Limitations– Loss of data at 6 months

Health related quality of life

• HRQOL – depression• HRQOL – depression and ECT• HRQOL – depression and ECT and NICE ‘03 + ‘09

N

Dep

ress

ion

seve

rity

scal

e

Ran

dom

al

loca

tion

Blin

ding

Sham

co

mpa

riso

n gr

oup

R

emiss

ion

crite

ria

Med

icat

ion

use d

urin

g tr

ial

Wav

e for

m

Trea

tmen

t te

rmin

ated

by

Freq

uenc

y of

tr

eatm

ent

Late

ralit

y

Freeman et al (1978)

40

HDRS Double

blind

Partial course

Regular medications maintained during trial

Sine wave

Treating clinical

team

Twice weekly

Bilateral

Lambourn & Gill (1978)

32

HDRS Double

blind Benzodiazepines only

Brief pulse

Treating clinical

team

Thrice weekly

Right Unilateral

Johnstone et al (1980)

70

HDRS Double

blind Benzodiazepines only

Sine Wave

Treating clinical

team

Twice weekly

Bifrontal

West (1981) 22

Visual analogue

scale

Double blind 50mg

amitriptyline at night

Sine wave

Treating clinical

team

Twice weekly

Bilateral

Brandon et al (1984)

77

HDRS &

MADRS

Double blind Benzodiazepines

only Sine wave

Treating clinical

team

Twice weekly

Bilateral

Gregory et al (1985)

69

MADRS &

HDRS

Double blind Benzodiazepines

only Sine wave

Treating clinical

team

Twice weekly

Bilateral and right unilateral

groups

Electroconvulsive therapy

• The UK ECT Review Group (2003) - meta-analysis: – Real ECT more effective than simulated ECT: – 9·7 point difference in HDRS

• Janicak et al (1985) – Meta-analysis:– MAOI – ECT more effective by 45%– Tricyclic – ECT more effective by 20%

• SSRI – ECT significantly more effective than Paroxetine (Folkerts et al. 1997): – 59% Vs reduction 29% reduction in HDRS score.