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

Objective Cognitive Performance Associated with Electroconvulsive Therapy for Depression: A Systematic Review and Meta-Analysis

Fundamentals of transcranial electric and magnetic stimulation dose: Definition, selection, and reporting practices

• In a random-assignment trial to unilateral right and bilateral electrode placements, electroconvulsive therapy (ECT) stimulus intensity was titrated to just above seizure threshold for each of 52 depressed patients. Seizure threshold was quantified in units of charge. There was a 12-fold range in the minimum electrical intensity necessary to produce seizure. Sex, age, electrode placement, and the cumulative number of treatments were each associated with seizure threshold. Bilateral ECT had both a higher initial seizure threshold and a greater cumulative increase in seizure threshold compared with unilateral ECT. Clinical and research implications are discussed with respect to dosing strategies in ECT.

Seizure threshold in electroconvulsive therapy: effects of sex, age, electrode placement, and number of treatments

Objective: The most common indication for electroconvulsive therapy (ECT) is major depression. It is less recognized that ECT is effective also in the treatment ofacute mania. This article aims to provide a comprehensive and critical review ofthe literature on the use of ECT for manic patients. Method: All published papers in the English language on the use of ECT in acute mania that could be found were reviewed with regard to efficacy, frequency and number of treatments, bilateral versus unilateral electrode placement, predictors of antimanic response, stability of therapeutic response, cognitive consequences, and other relevant issues. Results: The evidence indicates that ECT is associated with remission or marked clinical improvement in 80% of manic patients and that it is an effective treatment for patients whose manic episodes have responded poorly to pharmacotherapy. Manic patients do not require a high frequency or prolonged course of treatments to respond to ECT. The seizure threshold appears to be lower in manic patients than in depressed patients. The issues ofrelapse following response to E CT, cognitive consequences of E CT, and the relative merits of unilateral versus bilateral ECT in manic patients require further study. Conclusions: ECT is an effective and safe treatment for acute mania. Remission ofmania following ECT reflects a primary therapeutic effect rather than a secondary consequence ofan ECT-induced organic brain syndrome.

Electroconvulsive Therapy of Acute Manic Episodes: A Review of 50 Years' Experience

Current density in bilateral and unilateral ECT.

A comparison of standard alternating current and low-energy brief-pulse electrotherapy.

The threshold number of pulses in bilateral and unilateral ECT.

Studies in brief-pulse electroconvulsive therapy: the voltage threshold, interpulse interval, and pulse polarity parameters.

The purpose of this paper is to outline what we do and do not know about the electroconvulsive therapy (ECT) stimulus; the latter will require somewhat more time than the former. Papers that deal in any systematic way with the ECT stimulus comprise only a minute percentage of the literature. It ranges from difficult to impossible to say very much of a definitive nature based on our present fund of knowledge. We have many fragments of information but nothing approaching a systematic whole. Historically there are several roots to this problem. First, simple ordinary basic research was omitted. Essentially, the profession took whatever instruments manufacturers chose to provide-seldom based on clinical expertise and almost never on scientific data-and proceeded with treatment and clinical research on this basis. There were usually a few articles published each time a new machine was introduced, but we are unaware of any follow-up evaluative papers concerned with the design, utility, and shortcomings of the instrument. It took nearly 20 years before Davies et al , published an article critical of the MOLAC 11, pointing out that the three voltage settings were essentially equal.’ Curiosity about performance characteristics ought to have a shorter gestational period than that. This brings us to the second root: failure to do traditional dose-response investigations. There is almost a total lack of studies investigating the clinical and electrical results of the various stimulus parameter combinations available on any commercially produced instrument. This is as true for the Medcraft and MECTA instruments as it was for the Reiter CW, the MOLAC 11, and their predecessors. During the past five years, it has become more common for authors to mention the range of stimulus parameters employed, a practice that is a distinct improvement over those studies that compared ECT with antidepressant drugs and dismissed the stimulus with a succinct “ECT was given.” A third root has been failure to bring under experimental scrutiny and control basic physical factors relating to the ECT process. It has been known for many years that the resistance or impedance between the stimulating electrodes is inversely related to the energy actually reaching the brain. It was also known that measuring the resistance between electrodes with an ordinary ohmmeter gave no useful information regarding impedance as actually measured during treatment. Maxwell presented evidence that impedance diminished as voltage increased and that impedance could be considered constant above 135 volts? No study has been published that deals with variations in impedance within patient or between patients or the factors that produce these variations; nor has any study confirmed or taken issue with Maxwell’s findings. Regrettably, then, what we shall have to say regarding stimulus parameters must be regarded as tentative, pending the availability of more systematic research data. The quality of the published data is usually adequate; the deficiencies lie in the quantity and a suitable framework within which to place and evaluate such studies.

Williams R

Papers

Current density in bilateral and unilateral ECT.

A comparison of standard alternating current and low-energy brief-pulse electrotherapy.

The threshold number of pulses in bilateral and unilateral ECT.

Studies in brief-pulse electroconvulsive therapy: the voltage threshold, interpulse interval, and pulse polarity parameters.

Stimulus parameters and electroconvulsive therapy.