https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(03)12705-5.pdf

Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis

Objectives: 

To establish the clinical effectiveness and
cost-effectiveness of electroconvulsive therapy (ECT)
for depressive illness, schizophrenia, catatonia and
mania.

Data sources: 

Electronic bibliographic databases. The
reference lists of relevant articles and health services
research-related resources were consulted via the
Internet.

Review methods: 

Identified studies were examined to
ascertain whether they met the inclusion criteria for
the review. The study quality of relevant articles was
assessed using standard checklists and data were
abstracted using standardised forms into a database.
Where relevant, results from studies were pooled for
meta-analysis. Two economic models were developed
primarily based on evidence from the clinical
effectiveness analysis and limited quality of life
studies.

Results: 

Two good-quality systematic reviews of
randomised evidence of the efficacy and safety of ECT
in people with depression, schizophrenia, catatonia and
mania were identified. Four systematic reviews on nonrandomised
evidence were also identified, although
only one of these could be described as good quality.
There was no randomised evidence of the effectiveness
of ECT in specific subgroups including older people,
children and adolescents, people with catatonia and
women with postpartum exacerbations of depression
or schizophrenia. The economic modelling results for
depression did not demonstrate that any of the
scenarios had a clear economic benefit over the
others, mainly because of the uncertainty surrounding
the clinical effectiveness of the different treatments
and the quality of life utility gains. Sensitivity analysis
surrounding the cost of ECT and the quality of life
utility values had little effect on the overall results.
The results of the model for schizophrenia adapted
to include ECT suggest that clozapine is a cost-effective
treatment compared with ECT. For patients who
fail to respond to clozapine, ECT treatment may
be preferred to the comparative treatment of
haloperidol/chlorpromazine.

Conclusions: 

Real ECT is probably more effective than
sham ECT, but as stimulus parameters have an
important influence on efficacy, low-dose unilateral
ECT is no more effective than sham ECT. ECT is
probably more effective than pharmacotherapy in the
short term and limited evidence suggests that
ECT is more effective than repetitive transcranial
magnetic stimulation. Tricyclic antidepressants (TCAs)
may improve the antidepressant effect of ECT during
the course of treatment. Continuation
pharmacotherapy with TCAs combined with lithium in
people who have responded to ECT reduces the rate
of relapses. Overall, gains in the efficacy of the
intervention depending on the stimulus parameters of
ECT are achieved only at the expense of an increased
risk of cognitive side-effects. Limited evidence suggests
these effects do not last beyond 6 months, but there is
no evidence examining the longer term cognitive
effects of ECT. There is little evidence of the long-term
efficacy of ECT. ECT either combined with
antipsychotic medication or as a monotherapy is not
more effective than antipsychotic medication in people
with schizophrenia. More research is needed to
examine the long-term efficacy of ECT and the
effectiveness of post-ECT pharmacotherapy, the shortterm
and longer term cognitive side-effects of ECT, and
the impact of ECT on suicide and all-cause mortality.
Further work is needed to examine the information needs of people deciding whether to accept ECT and
how their decision-making can be facilitated. More
research is also needed on the mechanism of action of
ECT. Finally, the quality of reporting of trials in this area
would be vastly improved by strict adherence to the
Consolidated Standards of Reporting Trials
recommendations. Economic analysis may identify
areas in which research would be best targeted by
identifying parameters where reducing the level of
uncertainty would have the most effect in helping to
make the decision on whether ECT is a cost-effective
treatment.

Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: systematic reviews and economic modelling studies

We explore and illustrate the use of time series decomposition methods for evaluating and comparing latent structure in nonstationary electroencephalographic (EEG) traces obtained from depressed patients during brain seizures induced as part of electroconvulsive therapy (ECT). Analysis of the patterns of change over time in the frequency structure of such EEG data provides insight into the neurophysiological mechanisms of action of this effective but poorly understood antidepressant treatment, and allows clinicians to modify ECT treatments to optimize therapeutic benefits while minimizing associated side effects. Our work has introduced new methods of time-frequency analysis of EEG series that identify the complete pattern of time evolution of frequency structure over the course of a seizure, and usefully assist in these scientific and clinical studies. New methods of decomposition of flexible dynamic models provide time domain decompositions of individual EEG series into collections of latent co...

Evaluation and Comparison of EEG Traces: Latent Structure in Nonstationary Time Series

Therapeutic effectiveness of electroconvulsive therapy is influenced by the degree to which the stimulus intensity exceeds the seizure threshold. However, the threshold rises variably over the treatment course, confounding maintenance of desired relative stimulus intensity. In 47 depressed patients, decreases in relative stimulus intensity between treatments 1 and 6 were associated with diminished therapeutic response at treatment 6 for unilateral (UL) ECT. A multivariate model including manual ratings of ictal EEG data predicted whether seizure threshold rose with 82% accuracy. The same EEG variables were also significantly related to therapeutic response. Thus, decreases in relative stimulus intensity over the ECT course affect the therapeutic potency of UL ECT. Further, ictal EEG indices have considerable potential for predicting such stimulus intensity changes and their effect on therapeutic outcome.

Changes in seizure threshold over the course of electroconvulsive therapy affect therapeutic response and are detected by ictal EEG ratings

Major depressive disorder (MDD) is common and costly. Over the course of a year, between 13.1 million and 14.2 million people will experience MDD. Approximately half of these people seek help for this condition, and only 20 percent of those receive adequate treatment. For those who do initiate treatment for their depression, approximately 50 percent will not adequately respond following acutephase treatment; this refractory group has considerable clinical and research interest. Patients with only one prior treatment failure are sometimes included in this group, but patients with two or more prior treatment failures are a particularly important and poorly understood group and are considered to have treatment-resistant depression (TRD). These TRD patients represent a complex population with a disease that is difficult to manage.

Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults

Ictal EEG indices show promise for separating individual ECT seizures on the basis of treatment electrode placement (ELPL), relative stimulus intensity (Dose), and expected therapeutic response. One factor impeding the effective clinical implementation of ictal EEG indices for these purposes is uncertainty as to the relative utility of lower and higher frequency EEG activity. Recent articles are contradictory in this regard, but no data exist addressing this issue. As a result, we reanalyzed data from 44 subjects in two studies and compared the relative ability of ictal EEG data in three frequency bands to differentiate seizures as a function of ELPL, Dose, and therapeutic response. We found that the frequency band that best differentiated these groups depended on the EEG measure used, the temporal portion of the seizure, and whether ELPL, Dose, or therapeutic response was being compared.

The relative ability of three ictal EEG frequency bands to differentiate ECT seizures on the basis of electrode placement, stimulus intensity, and therapeutic response.

Spatiotemporal dynamic analysis of electroconvulsive therapy seizures

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The relative ability of three ictal EEG frequency bands to differentiate ECT seizures on the basis of electrode placement, stimulus intensity, and therapeutic response.

Spatiotemporal dynamic analysis of electroconvulsive therapy seizures