ECT Anesthesia: The Lighter the Better?

Background: Electroconvulsive therapy (ECT) is a most effective treatment for patients with major affective disorders. The influence of anesthetic drugs on seizure “adequacy” or on treatment success has not been systematically investigated. Methods: A bispectral EEG index score (BIS) was used to identify the depth of anesthesia during ECT. Our study included 22 major depressive episode (MDE) patients expanding to 219 ECTs (05/05-01/06) with no limitations of concurrent medication. Results: Fourteen out of the 22 patients showed full remission. Individual number of ECT sessions needed to reach full remission correlated negatively with mean pre-ECT BIS values (p=0.001). Additionally, using a repeated measurement regression analysis significant correlations were found for pre-ECT BIS versus motor response time, seizure concordance, ictal coherence and peak heart rate. Conclusion: The results of our study suggest BIS-levels as a predictor of faster ECT response. Controlling BIS-levels before stimulation may have an additional effect on treatment success.

References

• 1 Avramov MN, Husain MM, White PF. The comparative effects of methohexital, propofol, and etomidate for electroconvulsive therapy.  Anesth Analg. 1995;  81 596-602
• 2 Baumann B, Krell D, Dobrowolny H, Bielau H. Mechanisms of action in the prevention of recurrent mood disorders.  Pharmacopsychiatry. 2004;  37 ((Suppl 2)) S157-S164
• 3 Chanpattana W, Buppanharun W, Raksakietisak S, Vaughn MW, Somchai Chakrabhand ML. Seizure threshold rise during electroconvulsive therapy in schizophrenic patients.  Psychiatry Res. 2000;  96 31-40
• 4 Datto C, Rai AK, Ilivicky HJ, Caroff SN. Augmentation of seizure induction in electroconvulsive therapy: a clinical reappraisal.  J ECT. 2002;  18 118-125
• 5 Duman RS, Heninger GR, Nestler EJ. A molecular and cellular theory of depression.  Arch Gen Psychiatry. 1997;  54 597-606
• 6 Edwards M, Koopowitz LF, Harvey EJ. A naturalistic study of the measurement of seizure adequacy in electroconvulsive therapy.  Aust N Z J Psychiatry. 2003;  37 312-318
• 7 Fink M, Bailine S, Petrides G. Electrode placement and electroconvulsive therapy: a search for the chimera.  Arch Gen Psychiatry. 2001;  58 607-609
• 8 Folkerts H. The ictal electroencephalogram as a marker for the efficacy of electroconvulsive therapy.  Eur Arch Psychiatry Clin Neurosci. 1996;  246 155-164
• 9 Henn FA, Vollmayr B. Basic pathophysiological mechanisms in depression: what are they and how might they affect the course of the illness?.  Pharmacopsychiatry. 2004;  37 ((Suppl 2)) S152-S156
• 10 Henn FA, Vollmayr B, Sartorius A. Mechanisms of depression: the role of neurogenesis.  Drug Discov Today: Disease Mechanisms. 2004;  1 407-411
• 11 Kirstein L, Ottosson J. Experimental studies of electroencephalographic changes following electroconvulsive therapy.  Acta Psychiatr Scand. 1960;  145 49-68
• 12 Krystal AD. The clinical utility of ictal EEG seizure adequacy models.  Psychiat Ann. 1998;  28 30-35
• 13 Krystal AD, Weiner RD, Coffey CE. The ictal EEG as a marker of adequate stimulus intensity with unilateral ECT.  J Neuropsychiatry Clin Neurosci. 1995;  7 295-303
• 14 Lemmens HJ, Levi DC, Debattista C, Brock-Utne JG. The timing of electroconvulsive therapy and bispectral index after anesthesia induction using different drugs does not affect seizure duration.  J Clin Anesth. 2003;  15 29-32
• 15 Liu J, Singh H, White PF. Electroencephalogram bispectral analysis predicts the depth of midazolam-induced sedation.  Anesthesiology. 1996;  84 64-69
• 16 McCall WV, Farah BA. Greater ictal EEG regularity during RUL ECT is associated with greater treatment efficiency.  Convuls Ther. 1995;  11 69
• 17 McCall WV, Reboussin DM, Weiner RD, Sackeim HA. Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy: acute antidepressant and cognitive effects.  Arch Gen Psychiatry. 2000;  57 438-444
• 18 Nishihara F, Saito S. Adjustment of anaesthesia depth using bispectral index prolongs seizure duration in electroconvulsive therapy.  Anaesth Intensive Care. 2004;  32 661-665
• 19 Nobler MS, Sackeim HA, Solomou M, Luber B, Devanand DP, Prudic J. EEG manifestations during ECT: effects of electrode placement and stimulus intensity.  Biol Psychiatry. 1993;  34 321-330
• 20 Ochiai R, Yamada T, Kiyama S, Nakaoji T, Takeda J. Bispectral index as an indicator of seizure inducibility in electroconvulsive therapy under thiopental anesthesia.  Anesth Analg. 2004;  98 1030-1035
• 21 Perera TD, Luber B, Nobler MS, Prudic J, Anderson C, Sackeim HA. Seizure expression during electroconvulsive therapy: relationships with clinical outcome and cognitive side effects.  Neuropsychopharmacology. 2004;  29 813-825
• 22 Pritchett JT, Bernstein HJ, Kellner CH. Combined ECT and Antidepressant Drug Therapy.  Convuls Ther. 1993;  9 256-261
• 23 Rosow C, Manberg PJ. Bispectral index monitoring.  Anesthesiol Clin North America. 2001;  19 947-966
• 24 Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, Fitzsimons L, Moody BJ, Clark J. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities.  Arch Gen Psychiatry. 2000;  57 425-434
• 25 Sartorius A, Krier A, Andres FJ, Bender HJ, Krumm B, Henn FA. Bispectral index monitoring for more effective electroconvulsive therapy?.  Br J Anaesth. 2006;  96 806-807
• 26 Schmidt GN, Bischoff P, Standl T, Lankenau G, Hellstern A, Hipp C, Schulteam EJ. SNAP index and Bispectral index during different states of propofol/remifentanil anaesthesia.  Anaesthesia. 2005;  60 228-234
• 27 Sigl JC, Chamoun NG. An introduction to bispectral analysis for the electroencephalogram.  J Clin Monit. 1994;  10 392-404
• 28 Swartz CM. Physiological response to ECT stimulus dose.  Psychiatry Res. 2000;  97 229-235
• 29 Weiner RD. (ed) .The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association. Washington, DC 2001

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