Objective The purpose of this study was to determine which of the two commonly used schedules of ECT administration, twice or three times weekly, is clinically optimal in terms of antidepressant efficacy and cognitive effects. Method In this double-blind study, 52 consenting, medication-free patients with major depressive disorder, endogenous subtype (Research Diagnostic Criteria), were randomly assigned to bilateral, brief-pulse, constant-current ECT administered over 4 weeks at a rate of three times weekly or twice weekly with the addition of one simulated ECT (anesthesia and muscle relaxant only) per week. Outcome measures were the Hamilton Depression Rating Scale, Acute Cognitive Effects Battery, and Chronic Cognitive Effects Battery. Results Hamilton depression scale scores were significantly improved by both schedules, with no difference in outcome either 1 week or 1 month after the end of the ECT series. However, the rate of response to ECT three times a week was significantly faster and was related to the rate of real ECT administration. Cognitive effects were more prominent with ECT three times a week. Conclusions ECT twice a week is an effective schedule for clinical practice and is potentially advantageous in view of a therapeutic outcome identical to that of ECT three times a week and less severe cognitive effects. ECT three times a week may be specifically indicated when early onset of clinical effect is of primary importance.

Antidepressant and cognitive effects of twice- versus three-times-weekly ECT.

Onset and time course of antidepressant effect were examined in 47 patients with major depressive disorder who had been randomly assigned to twice weekly bilateral, brief pulse electroconvulsive therapy plus one simulated treatment per week (ECTx2) or to a three times weekly schedule of administration (ECTx3). Rapid improvement was observed in the ECTx3 group in whom the number of real ECTs to 30% reduction on the Hamilton Depression Scale (HAM-D) was 3.2 +/- 1.90, administered over 7.3 +/- 4.43 days and to 60% reduction, 5.9 +/- 3.09 real ECTs over 13.7 +/- 7.21 days. Among the responders in both groups combined, 24.3 +/- 29.58% of the overall improvement in HAM-D was contributed by the first real ECT, 60.9 +/- 28.13% by the first four real ECTs and 91.6 +/- 25.82% by the first eight. Although 85.3% of the responders had reached 60% HAM-D improvement after eight ECTs, a clinically significant minority (14.7%) responded later in the course (ECT 9-12). However, response was predictable on the basis of symptomatic improvement (30% on the HAM-D) by the sixth real ECT. Thirty-three out of 34 responders would have been correctly identified by this criterion and only 2 out of 13 non-responders mis-identified (P < 0.000001). Once achieved, the antidepressant effect was stable, without continuation pharmacotherapy, until 1 week after the last treatment and on lithium carbonate (Li) or Li plus clomipramine for a further 3 weeks. These findings confirm the clinical impression that ECT is a rapidly effective treatment for major depression with a shorter latency than generally reported for antidepressant drugs.(ABSTRACT TRUNCATED AT 250 WORDS)

Onset and time course of antidepressant action: psychopharmacological implications of a controlled trial of electroconvulsive therapy.

The adverse cognitive effects of electroconvulsive therapy are important limitations in the use of this treatment that continues to be a significant therapeutic strategy after 7 decades of use. Among the approaches to mitigation of these side effects are considerations involving the prescription and manipulation of the electrical stimulus itself. The impact of the following electrical factors on the cognitive outcomes of electroconvulsive therapy are surveyed: efficiency of the stimulus as expressed in electrical waveform; targeting of the stimulus, the major concept underlying electrode placement; stimulus dosing; and frequency and number of treatments. The current state of development of knowledge in these areas is summarized, and methods to achieve the best cognitive outcomes without sacrificing clinical efficacy are discussed. Future trends in the further optimization of the electrical stimulus are briefly mentioned.

Strategies to minimize cognitive side effects with ECT: aspects of ECT technique.

Electroconvulsive therapy (ECT) is an effective treatment for a variety of psychiatric syndromes. However, one of its adverse secondary effects is neurocognitive dysfunction. The aim of this paper is to review different subtypes of memory dysfunction associated with ECT from a neuropsychological perspective. Declarative memory is clearly impaired after ECT. Immediate memory, however, is broadly preserved. Few studies have addressed procedural and incidental memory. Selective memory is impaired, probably due to the disruption of specific brain regions. Some of the possible neurobiological bases of ECT memory dysfunction are discussed in this paper. Synaptic plasticity, the cerebral neurotransmission system, and cerebral metabolism are examined in relation to the dysfunction and subsequent recovery of each memory subtype.

Subtypes of memory dysfunction associated with ECT: characteristics and neurobiological bases.

BACKGROUND We compared the antidepressant and cognitive effects of up to eight sessions of bilateral, brief pulse electroconvulsive therapy (ECT) administered twice (ECT x 2) or three times weekly (ECT x 3), to confirm that ECT x 3 acts more rapidly although the two schedules are equivalent in antidepressant outcome, and to establish whether ECT x 3 is indeed associated with more severe memory impairment.

METHOD Patients with major depression, endogenous subtype were randomly assigned to ECT x 3 or ECT x 2 plus one simulated ECT per week, both up to a maximum of eight real ECT. Depression was evaluated by the Hamilton Depression Scale the day after each treatment and cognitive function by a test battery administered before and after the ECT series and at one month follow-up.

RESULTS Assessed categorically or parametrically, there was no significant difference in antidepressant outcome between the two schedules. Rate of response was significantly more rapid with ECT x 3 but was associated with more severe memory impairment.

CONCLUSIONS Twice weekly administration is an optimum schedule for bilateral ECT unless clinical indications require the more rapid antidepressant effect of three times weekly treatment.

Cost and benefit in the choice of ECT schedule. Twice versus three times weekly ECT.

The benefits and side effects of electroconvulsive therapy (ECT) given two vs three times per week were examined in depressed inpatients Twenty subjects were randomly assigned to one of two treatment conditions (unilateral ECT two or three times weekly) Examiners without knowledge of treatment condition rated depression and psychiatric status and administered tests of memory and visual-motor problem solving; subjects also provided self-ratings of depression Measures were collected before treatment and 2 and 4 weeks after treatment began Both schedules of treatment produced significant and equivalent improvements in psychiatric symptomatology, but visual memory impairment was significantly lower in the twice-weekly group

Albert Sattin

Papers

Effects of ECT given two vs. three times weekly.