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doi: 10.1097/YCT.0000000000000158
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A Pilot Study of Alternative Transcranial Direct Current Stimulation Electrode Montages for the Treatment of Major Depression

Kerrie-Anne Ho*, Siwei Bai†, Donel Martin*, Angelo Alonzo*, Socrates Dokos†, Pablo Puras*‡, Colleen K. Loo*§ From the *School of Psychiatry, University of New South Wales, Black Dog Institute; †Graduate School of Biomedical Engineering, University of New South Wales, Sydney, Australia; ‡Department of Psychiatry, Hospital Universitario de Getafe, Getafe, Madrid, Spain; and §Department of Psychiatry, St George Hospital, Sydney, Australia.

Financial Disclosures: Authors K.A.H., D.M., A.A., and C.K.L. are conducting another clinical trial of transcranial direct current stimulation, using equipment provided by the Soterix company. C.K.L. has received a research grant from the Stanley Medical Research Foundation to conduct a clinical trial of transcranial direct current stimulation in depression. C.K.L. reports no other biomedical financial interests or potential conflicts of interest.

Objective: This pilot study examined the feasibility, tolerability, and safety of 2 novel transcranial direct current stimulation (tDCS) electrode montages for the treatment of depression. The 2 montages, fronto-occipital (F-O) and fronto-cerebellar (F-C), were designed respectively to target the midline brain structures and the cerebellum.

Background: Typically, tDCS treatments have used bifrontal montages with anodal (excitatory) stimulation targeting the left dorsolateral prefrontal cortex. There is limited research examining the effects of alternative electrode montages for the treatment of depression.

Methods: Computational modeling was used to determine the electric fields produced in the brain regions of interest using the 2 alterative electrode montages compared with a standard bifrontal montage. The efficacy and safety of F-O tDCS (n = 8) and F-C tDCS (n = 7) were evaluated in an open label pilot clinical study of depressed participants. Mood and neuropsychological functioning were assessed at baseline and after 4 weeks of tDCS, administered daily on weekdays.

Results: Computational modeling revealed that the novel montages resulted in greater activation in the anterior cingulate cortices, cerebellum, and brainstem than the bifrontal montage, whereas electric fields in the dorsolateral prefrontal cortices were higher for the bifrontal montage. After 4 weeks of tDCS, overall mood improvement rates of 41.4% and 15.9% were observed in the F-O and F-C conditions, respectively, and no significant neuropsychological changes were found.

Conclusions: Initial results found both montages safe and feasible. Pilot results suggest that the F-O montage may have promising antidepressant potential.

Comparison of Efficacy of Ketamine Versus Thiopentone-Assisted Modified Electroconvulsive Therapy in Major Depression

Amit Jagtiani*, Hitesh Khurana*, Naveen Malhotra†, Raghu Gandhi* From the Departments of *Psychiatry, and †Anesthesiology, Pt. B.D. Sharma PGIMS, Rohtak, India.

Objective: The aim of this study was to compare the outcome of modified electroconvulsive therapy (ECT) in major depressive disorder patients undergoing ECT with thiopentone versus ketamine anesthesia.

Background: Evidence suggests that glutamatergic dysfunction—particularly the N-methyl-D-aspartate (NMDA) receptor complex—may play an important role in the pathogenesis of depression. The NMDA antagonists have been shown to have antidepressant effects. However, this issue is addressed only in few planned prospective studies with small samples.

Methods: Sixty hospitalized patients (age, 18–45 years) with major depressive disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) were randomly allocated to either of the 2 modified ECT groups receiving thiopentone or ketamine as the anesthetic agent. The subjects were assessed on a weekly basis on the Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI).

Results: The ketamine group required significantly lesser number of ECT sessions compared with the thiopentone group for achieving remission. The HAM-D and BDI scores were significantly lower in the ketamine group at the end of the first and second week. At the end of the ECT sessions, the mean BDI scores were similar in the 2 treatment groups, but the mean HAM-D scores were significantly lower in the ketamine group.

Conclusions: There was a rapid onset of response and earlier improvement in depression in the group receiving ECT with ketamine as the anesthetic agent. Thus, the use of ketamine (NMDA antagonist) as an anesthetic improved the efficacy of ECT for treatment of depression.

The Use of Simulation Center Technology to Standardize and Enhance Procedural Training in Electroconvulsive Therapy

Suzanne E. Kerns, MBBS*, Carol Simmons, MD†, Jeffrey Cluver, MD*, E. Baron Short, MD*, Nolan R. Williams, MD*, Edward Kantor*, Mark S. George, MD*, James Fox, MD* From the *Department of Psychiatry and Behavioral Science, Medical University of South Carolina; and †Medical University of South Carolina Simulation Center.

Disclosures: Dr Kerns receives partial salary support from the MECTA Corporation for work on a study of focal electrically induced seizure therapy. Dr Cluver has no disclosures to report. Dr Short receives external electroconvulsive therapy clinical research support from MECTA Corporation. Dr Williams has no disclosures to report. Dr Kantor has no disclosures to report. Dr George has no equity ownership in any device or pharmaceutical company. He does occasionally consult with industry. His total industry-related compensation is less than 10% of his total university salary per year. He acts as an unpaid consultant for, and receives external electroconvulsive therapy clinical research support, from MECTA Corporation.

Objective: The aim of this study was to determine if high fidelity simulation training and assessment for electroconvulsive therapy (ECT) was a feasible and effective means of standardizing and enhancing current models of clinical ECT training.

Background: Electroconvulsive therapy is a well-established, life-saving, psychiatric procedure. However, there are no national regulations for ECT training and certification, and the quality and nature of both remain highly variable. Other medical specialties have successfully used procedural training in simulation centers to standardize learning and improve quality of care.1–3

Methods: All senior psychiatric residents (n = 12) undergoing a clinical ECT elective in the spring of 2014 will be invited to participate in an ECT Simulation Center Assessment consisting of 3 skill stations followed by 4 full-case simulations. The simulation program tracks and records each participant’s performance, and both computer and live instructor feedback are provided immediately after the completion of each station. Precourse and postcourse procedural confidence, as well as postcourse impressions of the experience, are collected. Data collection is ongoing.

Results: A successful simulation center practice run has recently been completed by several residents who had undertaken earlier clinical ECT training. Residents showed appropriate knowledge, but displayed initial difficulty combining procedural skills in a cohesive manner. Difficulties improved with further simulated ECT practice. After a formal simulation center experience in April 2014, preliminary data will be available.

Conclusions: Simulation center procedural training has long been implemented within other medical specialties, and ECT simulations promise to be an equally feasible and effective means of standardizing and improving ECT training within psychiatry.


  1. 1. Epstein RM, Assessment in medical education. N Engl J Med. 2007;356:387–396.
  2. 2. Merien AE, van de Ven J, Mol BW, et al. Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review. Obstet Gynecol. 2010;115:1021–1031.
  3. 3. Rosen JM, Long SA, McGrath DM, et al. Simulation in plastic surgery training and education: the path forward. Plast Reconstr Surg. 2009;123:729–738; discussion 739–740.

Electroconvulsive Therapy With Polymyositis Clinical Outcome and Stability of CPK Case Report and Literature Review

Benjamin DeLucia, MD, Rachit Patel, MD, Adeeb Yacoub, MD, Andrew Francis, PhD, MD From the Department of Psychiatry and Behavioral Science, School of Medicine, State University of New York at Stony Brook, Stony Brook, NY.

Reprints: Benjamin DeLucia, MD, Department of Psychiatry, State University of New York at Stony Brook, HSC-T-10, Stony Brook, NY 11794 (e-mail:

The first author is a resident physician in training.

Background: Inflammatory myopathies, including polymyositis, may add risk to electroconvulsive therapy (ECT) from muscle sensitivity to depolarizing neuromuscular agents or from convulsive movements. Few reports describe ECT in this setting. Creatine phosphokinase (CPK) provides an index of disease activity in polymyositis. Three previous case series found elevations in CPK level in 12/12, 3/26, and 2/15, respectively, in patients without muscle disease with ECT.

Methods: Case report and literature review used MEDLINE.

Results: A 74-year-old woman developed initial onset of depression after steroid treatment of polymyositis. After failed medication trials, she started ECT and was treated with 30 inpatient and outpatient sessions for over 4 years. Each course of treatment was effective for depression without symptoms of muscle disease activity. During this period, there were 4 ECT sessions with pretreatment, posttreatment, and 4-hour posttreatment CPK values. The CPK level rose 37%, 29%, 12%, and 7% at 4 hours posttreatment and was unrelated to motor or EEG seizure length. Over the entire treatment period, there were 44 CPK measurements, which ranged from 786 to 3869 U/L (reference value, <174). The MEDLINE review found 2 cases of uneventful and successful ECT in patients with inflammatory myopathies.

Conclusions: The present case and the 2 published cases suggest that ECT can be safe and effective in inflammatory muscle disease. Our case is the first to report CPK monitoring and clinical outcome over an extended treatment course.

Treatment of Catatonia With Ultrabrief Right Unilateral Electroconvulsive Therapy A Case Series

Aaron J. Hauptman, MD, Joseph L. Kugler, MD, Samuel J. Collier, MD, Amy E. Walton, MD, Smitha. Murthy, MD, Linda G. Funderburg, MD, Keith S. Garcia, MD, PhD From the UT Southwestern Psychiatry Residency at the Seton Family of Hospitals, Austin, TX.

Objectives: The aim of this study was to illustrate the effectiveness of ultrabrief (UB) right unilateral (RUL) electroconvulsive therapy (ECT) for the treatment of catatonia in a diverse patient population.

Background: Catatonia is a heterogeneous syndrome with regard to presenting symptoms and etiological context. Electroconvulsive therapy remains the first-line treatment of catatonia regardless of presentation or etiology. Emerging evidence from studies comparing RUL to bilateral (BL) ECT in depressed patients suggests equal efficacy with RUL ECT resulting in less cognitive impairment. Delivering electrical charge with UB pulse width (<0.5 ms) during RUL ECT further improves ECT adverse effect profile. Literature review reveals only a few published case reports on the use of RUL ECT in catatonia, 1 case report on UB RUL ECT, and an absence of evidence on the relative effectiveness and tolerability of RUL versus BL ECT in this condition. The paucity of publication on this technique suggests that application of UB RUL ECT is likely underused in catatonia treatment.

Methods: Three-year retrospective chart review of catatonic patients treated in the ECT department at Shoal Creek Hospital, Austin, Tex. Psychiatric, medical, and malignant catatonia presentations are represented in the patient sample.

Results: Of 13 catatonic patients treated, 11 had rapid symptom resolution with UB RUL ECT with minimal adverse effects. Two patients who did not improve with RUL ECT were switched to BL ECT, which provided no additional symptom benefit.

Conclusions: Our experience suggests that UB RUL ECT can be rapidly effective for the treatment of catatonic symptoms in a diverse population of catatonic patients.

Resting State Connectivity as a Biomarker of Early Response to Electroconvulsive Therapy

Miklos Argyelan, MD*, Styliani Kaliora, MD*, Noah L Weissman, MSc*, Peter B Kingsley, PhD†, Anil K Malhotra, MD*, Philip R Szeszko, PhD*, Georgios Petrides, MD* From the *Division of Psychiatry Research, Zucker Hillside Hospital, North Shore-LIJ Health System, Glen Oaks; and †Department of Radiology, North Shore University Hospital, North Shore-LIJ Health System, Manhasset, NY.

Objective: The aim of this study was to study the resting state fMRI (rsfMRI) changes before and after a course of electroconvulsive therapy (ECT) and their relationship to antidepressant response.

Background: There are no reliable biomarkers of response to ECT. The rsfMRI is an informative method of assessment of brain functional connectivity, which has been implicated in playing an important role in mood regulation.

Methods: Sixteen depressed patients (48.1 ± 12.6 y; 6 females) underwent rsfMRI before the first ECT (TP1), within 36 hours after the first ECT (TP2), and within 36 hours after the last or eighth ECT (TP3) (whichever occurred first). Electroconvulsive therapy was performed with bifrontal placement at 1.5 times seizure threshold. Patient’s symptoms were assessed with the Hamilton Rating Scale for Depression. Remission was defined as 2 consecutive Hamilton Rating Scale for Depression score less than or equal to 10. Twelve patients remitted. Ten healthy controls (45.6 ± 12.0 y; 5 females) underwent the same fMRI protocol at the same intervals. Fractional amplitude of low frequency fluctuations (fALFFs) maps was assessed voxelwise with statistical parametric mapping (cluster corrected P < 0.05); we compared TP1 versus TP3.

Results: At baseline, depressed patients had higher fALFF than controls in the subgenual cingulate cortex. This difference decreased over the course of treatment, with significant effects observed after the first ECT. No changes were seen in healthy controls. In remitters versus nonremitters comparisons, we observed that decreases in fALFF were present only in remitters.

Conclusions: Electroconvulsive therapy responders showed increased resting state fALFF at the subgenual cortex that decreased with treatment, whereas healthy controls and nonresponders showed no changes. “Normalization” of subgenual cortex fALLF activity may be a biomarker of response to ECT.

Electroconvulsive Therapy in Youth in a Tertiary Academic Center An 11-Year Experience

Styliani C. Kaliora, Eugene Grudnikoff, Zainab Al-Dhaher, Neil Mori, Ketankumar Hirapara, Christoph U. Corell, George Petrides

Background: Electroconvulsive therapy (ECT) is a safe and effective treatment for adults but rarely used in youth.

Objective: The aim of this study was to assess indications, effectiveness, and safety of ECT in a pediatric patient cohort treated at a psychiatric hospital.

Methods: A retrospective chart review of youth aged younger than 19 years treated with immediate ECT between 2000 and 2011 was performed. Response was defined by documented substantial symptom reduction, minor residual symptoms, and increased GAF score, whereas remission was defined as no residual symptoms.

Results: Forty-six youth (mean age, 17.1 ± 1.7 years; range, 13.02–19.97) with an average duration of illness 36.2 ± 27.3 months received ECT; 76.2% had history of psychiatric hospitalizations, and 18.2% previously underwent ECT. The most common diagnosis was unipolar depression (27.9%) followed by schizophrenia/schizophreniform disorder (25.6%), psychosis NOS (16.3%), schizoaffective disorder (9.3%), bipolar depression (7.0%), bipolar mania (7.0%), and OCD (2.3%). Patients received a median number of 8 (IQR, 6–14.3) bifrontal ECT treatments. Of 81.4% responders, 40% remitted fully. Response rate was significantly higher for unipolar (100%) and bipolar depression (100%) than other diagnoses (P = 0.036). The response rates for the other diagnoses were as follows: schizophrenia/schizophreniform disorder, 81.8%; psychosis NOS, 85.7%; and schizoaffective disorder, 75%. Treatments were well tolerated. Cognitive function, measured by a 10-point scale, improved by 8.5 (IQR, 7–10) to 9 (IQR, 9–10) points. Adverse events included prolonged seizure (27.3%) postictal agitation (18.2%), headache (11.4%), tachycardia, and nausea (6.8% each).

Conclusions: In our youth sample, ECT was safe and effective, particularly in those with depression and primary psychotic disorders. Controlled trials are needed to elucidate long-term benefits and risks of ECT in youth.

Verbal Fluency as a Predictor of Retrograde Autobiographical Memory After Electroconvulsive Therapy

Donel Martin*†, Veronica Galvez*†, Colleen Loo*†‡ From the *Black Dog Institute; †School of Psychiatry, University of New South Wales; and ‡St George Hospital, South Eastern Sydney Health, Sydney, Australia.

Objective: The aim of this study was to examine consistency in verbal fluency performance as a predictor of changes in retrograde autobiographical memory over a course of electroconvulsive therapy (ECT).

Background: Electroconvulsive therapy is commonly associated with deficits in retrograde autobiographical memory that can be distressing for patients. Autobiographical memory, however, is not commonly assessed in clinical settings due in part to time restraints. Verbal fluency measures are sensitive to the effects of ECT and brief to administer, and performance may share a common neural network for retrieval of autobiographical memories.

Methods: The Columbia Autobiographical Memory Interview–Short Form (AMI-SF) and verbal fluency measures (FAS and animals) were administered at pre-ECT, post-ECT 6, and again at posttreatment in 121 depressed participants in a double-blind, randomized controlled trial of ultrabrief (0.3 ms) versus brief (1.0 ms) pulse width ECT. Regression analysis examined predictors of consistency in AMI-SF performance at post-ECT 6 and at posttreatment.

Results: At posttreatment, consistency in FAS performance (P = 0001) and time to reorientation post-ECT 6 (minutes) (P = 0.012) were significant predictors in the model. The association between consistency in verbal fluency and AMI-SF performance was strongest in patients who received right unilateral ECT (r = 0.46, P < 0.001, n = 85) and was comparable in magnitude to time to reorientation immediately after ECT 6 (r = −0.55, P < 0.001, n = 66).

Conclusions: Consistency in verbal fluency performance may serve as a proxy measure for changes in retrograde autobiographical memory performance after a course of right unilateral ECT.

Predictors of Seizure Threshold in Right Unilateral Ultrabrief Electroconvulsive Therapy

Verònica Gálvez*†, Colleen K Loo*†‡ *School of Psychiatry, University of New South Wales; †Black Dog Institute; and ‡Department of Psychiatry, St George Hospital, Sydney, Australia.

Objective: The aim of this study was to analyze the relationship between seizure threshold (ST) and clinical and demographic factors in a sample of patients treated with right unilateral ultrabrief (RUL-UB) electroconvulsive therapy (ECT).

Background: An individualized approach to maximize ECT efficacy and minimize cognitive adverse effects is to treat patients relative to their ST. Several factors have been found to predict ST in brief pulse (pulse width 0.5–1.5 ms) ECT. However, although RUL-UB ECT (pulse width 0.3 ms) is increasingly used clinically, there are minimal data regarding predictors of ST.

Methods: One hundred eighty patients treated with RUL-UB ECT were examined retrospectively in regards to clinical, demographic, and ECT data. Seizure threshold was titrated at the first ECT session. Electroconvulsive therapy was performed with a Thymatron or MECTA device, with thiopentone (3–5 mg/kg) or propofol (1–2 mg/kg) anesthesia. Medications taken during ECT were documented. Candidate predictor variables were first tested in univariate analyzes. Variables found to be significant at P < 0.1 in univariate analyses (age, anesthetic type) were then entered in a multivariate regression analysis together with sex, anticonvulsants, and benzodiazepines.

Results: Multivariate regression analysis yielded a significant model (P < 0.001) and found only age (t = 4.93, P < 0.001) to be a significant predictor of ST. Concurrent treatment with anticonvulsants or benzodiazepines and type of anesthetic were not significant predictors of ST.

Conclusions: In line with previous results for brief pulse ECT, age was identified as a predictor of ST for RUL-UB ECT.

Exploring the Effect of Caffeine on dTMS Treatment Outcomes in Major Depressive Disorder Patients in a Real-World Clinical Setting

Zia Choudhry, MD, PhD, Ryan Nathan, Megan Conroy, William Duffy, Wendy Huynh, Walter Duffy, M.D From the Departments of Pharmacogenetics, Neuromodulation, and Clinical Research, Premier Psychiatric Group.

Reprints: Walter Duffy, MD (e-mail:

Objective: The aim of this study was to explore the effect of caffeine on dTMS treatment outcomes in major depressive disorder (MMD) patients in a real-world clinical setting.

Background: Studies exploring the effect of caffeine consumption on symptoms of depression have yielded mixed findings. Given that caffeine increases motor excitability, it may modulate transmagnetic stimulation treatment in patients with MMD. However, to our knowledge, there has been no study to date that has examined the effect of caffeine use on modulating dTMS treatment using H-coil technology in patients with depression.

Methods: Thirty-three patients (72% female) with MDD, ages 24 to 67 years (mean, 45.45), received dTMS. Among these patients, 27 (81%) reported habitual caffeine use. Depressive symptom severity (DSS) was assessed using the Zung Self-Rating Depression Scale at baseline and every 5 treatments subsequently. Patients received immediate (20 sessions) and maintenance-phase (10 sessions) dTMS treatments. The effect of caffeine use on dTMS efficacy was evaluated using repeated measure analysis of variance to contrast baseline with postimmediate and maintenance treatment paradigms.

Results: All patients reported significantly reduced DSS after dTMS treatment assessed with the Zung Self-Rating Depression Scale. However, a significant effect of caffeine use was observed on dTMS treatment both postimmediate and maintenance phases (P = 0.037, P = 0.035). Specifically, caffeine users reported a significantly greater decrease in DSS scores postimmediate and maintenance treatment.

Conclusions: These results suggest that patients who are caffeine users report a greater decrease in DSS scores postimmediate and maintenance treatment. However, further research with a larger sample size is warranted to reach firmer conclusions.

Exploring Possible Association Between Age and dTMS Treatment Outcomes Using H-Coil Technology in a Naturalistic Clinical Setting

Zia Choudhry, MD, PhD*, Alexander Bystritsky, MD, PhD†, Ryan Nathan*, Megan Conroy*, William Duffy*, Wendy Huynh*, Walter Duffy, MD* Departments of *Pharmacogenetics, Neuromodulation, and Clinical Research, Premier Psychiatric Research Institute; and †Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine and UCLA Anxiety Disorder Program.

Reprints: Walter Duffy, MD (e-mail:

Objective: The aim of this study was to explore the effect of age on dTMS treatment outcomes in major depressive disorder (MDD) patients in a real-world clinical setting.

Background: Empirical evidences regarding age effects in MDD treatment outcomes are mixed. Most believe that elderly depressed patients are harder to treat and more likely to relapse. In addition, a 10-year follow-up study showed that depression is a risk factor for all-cause mortality in the elderly. Neurobiological studies also show age-related changes in the brain, potentially contributing to depression. To date, no study has examined age as a modulator of dTMS treatment using H-coil technology in MDD patients.

Methods: Forty-six MDD patients (60% female), ages 18 to 84 years (mean, 45), received dTMS. Depressive symptom severity (DSS) was assessed using the PHQ-9 questionnaire at baseline and every 5 treatments subsequently. All patients (<55 vs >55 years) received immediate (20 sessions) and maintenance-phase (10 sessions) dTMS treatment. The effect of age on dTMS efficacy was evaluated using repeated measure analysis of variance contrasting baseline with postimmediate and maintenance paradigms.

Results: All patients significantly reduced DSS after dTMS treatments. However, a significant effect of older age (>55 years, n = 11) was observed on dTMS treatment both postimmediate and maintenance phases (P = 0.006, P = 0.030). Specifically, older patients reported greater decrease in DSS scores after both treatment paradigms.

Conclusions: These results suggest that older age patients report a significantly greater decrease in DSS scores postimmediate and maintenance dTMS treatments. However, further research with a larger sample size is warranted to reach firmer conclusions.

Trends in ECT Utilization in the Medicare Fee-For-Service Population 2000 to 2012

Patrick Ying, MD

Objective: The aim of this study was to determine the frequency of use of electroconvulsive therapy (ECT) by Medicare beneficiaries and examine the trend over the last decade and among the 50 states.

Background: A recent report has suggested that the use of ECT has been declining in general hospitals (case, 2013). Limitations of these data included the inability to capture outpatient ECT and the use of ECT in freestanding psychiatric hospitals. Medicare is a significant payor for important ECT populations. Analysis of Medicare claims data can capture ECT use not available in the prior analysis.

Methods: Data sets representing Medicare part B claims were downloaded from the Web site, from 2000 to 2012 as well as a recent data set, representing provider-level claims in 2012. Rates of usage for CPT codes representing ECT, psychiatric evaluations, and total number of Medicare beneficiaries were determined for the years 2000 to 2012. For the year 2012, state level data regarding the number of ECT providers, ECT patients, and ECT treatments were extracted.

Results: The number of ECT claims in the Medicare part B system fell from 154,239 to a low of 133,303 in 2008 and has slightly recovered in 2012 to 143,366, whereas total FFS part B beneficiaries and claims for psychiatric evaluations increased. In 2012, Medicare reported claims for ECT in 47 states and the District of Columbia, but none in Alaska, Montana, and Wyoming.

Conclusions: The data seem to confirm a decrease in the use of ECT over 2000 to 2012, although not to the extent previously reported. Efforts to support ECT programs and education should continue.

Transcranial Magnetic Stimulation for Depression Associated With Fibromyalgia A Case Series

Moacyr Alexandro Rosa, Guilherme Lozi Abdo, Luciana Sarin, Marina Odebrecht Rosa, Daniel Feldman, José Alberto Del Porto Rua Vergueiro, 1855 cj. 46 Sao Paulo, SP, Brazil.

Objective: The aim of this study was to evaluate the effects of rTMS in the treatment of patients with comorbid depression and fibromyalgia. Effects on depressive symptoms, fibromyalgia symptoms, and quality of life were evaluated.

Background: In addition to its known benefits in the treatment of major depression, rTMS is being tested for the treatment of fibromyalgia, a condition that manifests with pain and is often associated with depression.

Methods: In this case series, 7 patients with depression (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) and fibromyalgia received daily sessions of rTMS over the left dorsolateral prefrontal cortex (F3 point of the 10/20 EEG system; intensity, 100% of motor threshold; frequency, 10 Hz; train duration, 10 seconds; intertrain interval, 20 seconds: number of pulses per session, 6000). A total of 10 sessions was given. A neuro-MS stimulator was used. Depressive symptoms (Hamilton scores), pain (Fibromyalgia Impact Questionnaire), and quality of life (SF-36) were rated at baseline and after treatment.

Results: Six of 7 patients achieved remission of depressive symptoms. Fibromyalgia symptoms were also relieved in all but 1 (same without antidepressant effect) and amelioration of quality of life followed the same pattern.

Conclusions: rTMS was very efficacious for the treatment of depression and fibromyalgia symptoms in this population.

Quality of Life in Geriatric Depression Preliminary Data From Phase I of the PRIDE Study

Peter B. Rosenquist, W. Vaughn McCall, Charles H. Kellner, Rebecca G. Knapp, Martina Mueller, Georgios Petrides, Mustafa M. Husain, Robert C. Young, Robert M. Greenberg, Shawn M. McClintock, Joan Prudic, Richard D. Weiner, Sarah H. Lisanby, Prolonging Remission in Depressed Elderly Group

Objective/Background: Major depressive disorder significantly impairs quality of life (QOL). Previous studies examining QOL in patients referred for electroconvulsive therapy (ECT) have not focused on geriatric depression. We report preliminary results of baseline QOL in a cohort of depressed elderly (aged >60 years) who participated in the phase I of the Prolonging Remission in Depressed Elderly (PRIDE) study.

Methods: The PRIDE study is an NIMH-supported, multisite clinical trial of treatment outcomes for unipolar depressed geriatric patients referred for ECT. We assessed QOL at baseline with the Medical Outcomes Study Short Form 36 (SF-36) and calculated 8-subscale profile of functional health and well-being scores as well as Physical and Mental Composite Scores. Comparisons between the study sample and age-matched normative scores (SF-36 version 2; 1998 general US population) were conducted with single-sample t tests.

Results: As of December 2013, 197 patients had entered phase I of the PRIDE study. Baseline QOL was significantly impaired relative to an age-matched normal sample across all subscales of the SF-36. With the exception of the Physical Functioning subscale, advancing age within the sample was associated with less impairment.

Conclusions: Depressed elderly patients referred for ECT show significant QOL impairments relative to normal age-matched controls. “Young-old” depressed patients reported lower quality of life in mental health subscales compared with “old-old” patients. This relative difference may be indicative of differential pattern of referral for ECT or possibly reflect resiliency with advancing age.

Effect of Using Remifentanil With Propofol for Electroconvulsive Therapy

Jerry Varghese, Kate Farrugia, Rebecca Madge*, Murray Parkinson† From the *Electroconvulsive Treatment Team, Department of Psychiatry, and †Department of Anesthesia, MidCentral DHB, Palmerston North Hospital.

Objective: This study aims to look at the benefits of using remifentanil as a preinduction agent and test a number of hypotheses derived from a review of literature.

Background: Remifentanil has been shown to improve the quality and duration of seizures. The anesthesia-sparing effects of remifentanil were also noted. We hypothesized that with better seizures and improved cognitive adverse effects, we could see a shorter course of treatment.

Methods: Preinduction with remifentanil was added to the existing anesthesia protocol. Data collected included the dose of the anesthetic agents used and quantitative seizure measures. The duration of a course of ECT treatment was compared across the 2 protocols.

Results: Propofol alone required average doses of 157.43 mg compared with 87.93 mg with remifentanil preinduction. Both motor and EEG seizure length were longer in the remifentanil group. There was an average increase of 5 seconds in motor seizures and as much as 11 seconds more in EEG seizures. There was no significant difference in the average number of treatments per acute course in the propofol group (12.45) compared with the remifentanil plus propofol group (10.82).

Conclusions: Our study confirmed the anesthesia-sparing effects of remifentanil, leading to lower doses of propofol. This could also explain the improved quality of seizures—both motor and EEG. Our study did not demonstrate a shorter course of treatment, with other factors such as the pulse width of stimulus used and or the prescriber’s choice to stop treatment being better explanations for the duration of a course.

Role of Mindfulness-Based Psychological Support During a Course of ECT

Kate Farrugia, Jerry Varghese, Rebecca Madge* From the *Electroconvulsive Treatment Team, Department of Psychiatry, MidCentral DHB, Palmerston North, New Zealand.

Objectives: This explorative study looks at the possibility, effectiveness, and benefits of providing psychological interventions for individuals undergoing a course of electroconvulsive therapy (ECT).

Background: A review of literature showed that little has been done combining psychological support and ECT concurrently. Nevertheless, McClintock et al (J ECT. 2011;27:236) suggested that with proper adaptation, depression-specific psychotherapy can be personalized as an augmentation intervention to meet the needs of severely depressed patients treated with ECT.

Methods: A retrospective file review of case notes and interviews were thematically analyzed. Cognitive testing provided information around impairment or difficulty with retention of information. Symptom profile and severity as a contributing factor was assessed.

Results: The thematic analysis produced the following categories: anxiety reduction, improved insight, better use of support structures, building trust and confidence, and working toward recovery.

Conclusions: Patients were cognitively intact to engage in simple mindfulness-based psychotherapy, with no evidence of difficulty with recollection of new information, and actually use strategies to work toward their recovery. This study confirms the cognitive adverse effect–sparing benefits of ultrabrief pulse ECT (Sienaert et al J Affect Disord. 2010;122:60–67) but goes on to prove that psychological interventions and physical modalities of treatment are not mutually exclusive and can in fact be complimentary to each other.


  • 1. McClintock SM, Brandon AR, Husain MM, et al. A systematic review of the combined use of electroconvulsive therapy and psychotherapy for depression. J ECT. 2011;27:236.
  • 2. Sienaert P, Vansteelandt K, Demyttenaere K, et al. Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: cognitive side-effects. J Affect Disord. 2010;122:60–67.

Response Without Remission With Right Unilateral Ultrabrief Pulse ECT Switch to Brief Pulse Unilateral ECT Can be Effective. A Report of 2 Cases

Holly D. Dornan, MD, FRCPC, Lisa McMurray, MD, FRCPC From the Department of Geriatric Psychiatry, University of Ottawa, Royal Ottawa Mental Health Centre, Ottawa, Ontario, Canada.

Reprints: Lisa McMurray, MD, FRCPC, Royal Ottawa Mental Health Centre, 1145 Carling Ave, Ottawa, Ontario, Canada, K1Z 7K4 (e-mail:

The authors have no conflicts of interest or financial disclosures to report.

Objective: The aim of the study was to examine a clinical strategy in the management of partial responders to right unilateral ultrabrief pulse electroconvulsive therapy (ECT).

Background: Electroconvulsive therapy is 1 of the most effective treatments in psychiatry. New research involving different electrode placements and pulse widths has allowed us to be more precise in giving effective ECT while minimizing cognitive adverse effects. However, controversy exists in the ECT community over the preferred technique. Presently, there are relatively few randomized controlled trials to guide practitioners in their choices.

Methods: We describe 2 cases of geriatric patients with major depressive disorder who achieved a response but not remission with a course of right unilateral ultrabrief pulse (RUL-UB) ECT, as evidenced by a plateau in the depression scores (measured using the Montgomery-Åsberg Depression Rating Scale) after 10 and 12 treatments of RUL-UB ECT.

Results: In both instances, the patients achieved complete remission in their depressive symptoms after a switch to right unilateral brief pulse ECT. For both of the patients, there was no evidence of cognitive adverse effects with either pulse widths. A switch to bilateral ECT was not required, therefore allowing both patients to attain remission while preserving the cognitive advantages of the right unilateral electrode placement.

Conclusions: These cases add to an emerging literature surrounding the decreased efficacy of RUL-UB ECT. We propose that a personalized, algorithm-driven approach in choosing electrode placement and pulse width could lead to better patient outcomes and clinical care.

A Pilot fMRI Study on the Effects of ECT on the Brain Functional Connectivity and Its Relationship to the Antidepressant Effect

Chuanjun Zhuo, Hongru Qu, Xiaolei Ma, Qingying Xu

Reprints: Chuanjun Zhuo, Anning Hospital of Tianjin City, Dongli District, Tianjin, 300300, People’s Republic of China.

Objective: The aim of this study was to investigate the brain functional connectivity changes and its relationship to the antidepressant effect in the patients with treatment-resistant depression before and after the completion of electroconvulsive therapy (ECT) treatment.

Background: Previous functional magnetic resonance imaging studies show that ECT induces changes in brain functional connectivity, but the lack of agreement among these studies makes it difficult to draw conclusions about the effect of the ECT on brain functional connectivity and its relationship to the antidepressant effect of ECT.

Methods: fMRI scans were performed 3 to 5 days before and after the completion of modified ECT treatment sessions in 3 patients with treatment-resistant major depression disorders. fMRI images were processed and analyzed using the SPM8 software.

Results: After the treatment of ECT, the functional connectivity between dorsal lateral prefrontal cortex and bilateral temporal lobe, right occipital lobe, and right limbic lobe was decreased. The brain functional connectivity decreased between dorsal lateral prefrontal cortex and bilateral temporal lobe and showed a trend of correlation with improvement of depressive symptoms.

Conclusions: Our study indicates that brain functional connectivity changes were observed after the treatment of ECT, but achieving the objectives of identifying specific neuroimaging markers based on pre-ECT scans may help to predict treatment response, and developing individualized optimal treatment plans, further investigations with larger sample sizes, validated methods, and longitudinal design may help to clarify the exact brain functional changes induced by ECT and help to explore the neural mechanisms of the effect of ECT in the treatment of depression.

Gray Matter Volume Increase After Electroconvulsive Therapy in Late-Life Depression

Filip Bouckaert*†, François-Laurent Dewinter*, Louise Emsell*, Annemieke Dols‡, Martien Wampers*, Jasmien Obbels†, Max Stek‡, Pascal Sienaert†, Mathieu Vandenbulcke* Departments of *Old Age Psychiatry, and †Mood Disorders and ECT, UPC KULeuven, Belgium; and ‡Department of Old Age Psychiatry, GGZinGeest/VUmc, the Netherlands.

Pascal Sienaert is the presenting author of this study.

Objective: The aim of this article was to study the effect of electroconvulsive therapy (ECT) on gray matter volume in patients with severe late-life depression.

Methods: Twenty-eight elderly patients (mean age [SD], 71.9 [7.8]; 7 males) with treatment refractory depression were treated twice weekly with right unilateral brief pulse ECT until sustained remission on Montgomery-Åsberg Depression Rating Scale was reached. Cognition and psychomotor changes were monitored respectively with MMSE and CORE at baseline and 1 week after the last ECT. We used the t test procedure to assess change of clinical measure (SAS). At both time points, structural magnetic resonance imaging (MPRAGE sequence on a 3-T Philips scanner) was performed. We used voxel-based morphometry (VBM8 toolbox in SPM8) to study gray matter volume changes and conducted a whole-brain analysis using a paired t test to compare pre-ECT and post-ECT gray matter volume. The threshold was set at voxel-level FWE-corr P < 0.05 with an extent threshold of 50 voxels.

Results: Patients received a mean of 11.2 ECT sessions (SD, 4). There was a significant decrease in depressive symptoms (P < 0.0001). Remission rate was 78.6%. Cognition improved significantly (P < 0.001), as well as psychomotor agitation (P < 0.0001) and psychomotor retardation (P < 0.0001). We found significant right hemispheric gray matter volume increase in caudate nucleus area, medial temporal lobe (including hippocampus), anterior and posterior insula, and posterior superior temporal area.

We did not find a correlation with our primary response variable (Montgomery-Åsberg Depression Rating Scale), but a significant correlation between percent change in the nucleus caudate cluster with the total CORE score (r = 0.63, P = 0.0003) and subcluster noninteraction (r = 0.67, P = 0.0001).

Conclusions: These preliminary findings suggest that ECT in patients with late-life depression is associated with gray matter volume increase. The significant increase of ipsilateral to the stimulation side suggests a regional response within the brain tissue related to the pulse. However, the correlation of percentage volume increase of the caudate cluster with the change of CORE score indicates interesting and potentially specific clinical associations that need further investigation.

Treatment of Catatonia in the Medical ICU with ECT Delay in Treatment Due to Legal “Protections” in California

Brian P. Miller, MD, Nicole Garces-Barrella, RN From the Sharp HealthCare, Grossmont Hospital, La Mesa, CA.

Reprints: Brian Miller, MD, Grossmont Hospital 5555 Grossmont Center Dr, La Mesa, CA 91942 (e-mail:

Disclosures: none pertinent.

Electroconvulsive therapy (ECT) is known to be effective for episodes of catatonia related to psychiatric illness. Electroconvulsive therapy has also been used for catatonia associated with medical and neurological conditions. We report the case of a patient with a history of schizophrenia, but no prior episodes of catatonia, who had a prolonged episode of unresponsiveness associated with severe medical illness. Electroconvulsive therapy was recommended, but there was a significant delay in starting treatment based on the current legal requirements in California for patients who are unable to provide consent for the procedure.

C.P. was a 69-year-old woman admitted to the medical floor with complaints of fatigue and shortness of breath. Her condition was diagnosed with pneumonia, and she started on appropriate antibiotics. At the time of admission, she was alert, oriented, and able to feed herself. On day 5 of her hospital stay, she developed respiratory arrest requiring intubation. The endotracheal tube was believed to be in the trachea, but after being transferred from the floor to the ICU, it was found to be in the esophagus. Oxygen saturations remained in the 60s for several minutes. She was maintained with mechanical ventilation, but even as her pulmonary condition improved, she was completely unresponsive. Neurological consultation was obtained to evaluate for anoxic brain injury. Brain magnetic resonance imaging did not demonstrate any demyelization or other immediate changes. EEG showed diffuse slowing. Cold calorics resulted in slight nystagmus away and slow tonic deviation to the cold side. With the absence of any other explanation for her unresponsive state, catatonia was diagnosed, and psychiatric consultation for consideration of ECT was obtained. Because she was unable to provide an informed consent, a petition was submitted to the Superior Court asking for a surrogate decision maker. In California, this requires consultation by 3 psychiatrists with a unanimous decision that ECT is indicated and that the patient is unable to provide consent. The process took 2 weeks during which time she received intravenous lorazepam up to 12 mg a day in addition to trials of zolpidem, quetiapine, and olanzapine, all without apparent benefit. She remained unresponsive even to painful stimuli. Electroconvulsive therapy was started 20 days after her respiratory arrest. Before treatment, her Bush-Francis score was 23. She was initially given daily bilateral treatments. After the first treatment, she began opening her eyes to verbal command. By her third treatment, she was convincingly following commands and visually tracking her environment. In addition, her Bush-Francis score dropped to 15, and she began CPAP trials in preparation for extubation. Treatments were then given every other day with a Bush-Francis score of 7 after a total of 6 treatments. The day after her last ECT, she was extubated. However, 2 days later, she again developed respiratory failure with oxygen saturations in the 70s despite high flow BiPAP. Bronchoscopy revealed mucus plugging; arterial blood gasses showed persistent respiratory acidemia, and she was tachypneic and ultimately required reintubation. With the prospect of long-term tracheostomy and gastrostomy tube feedings, she was referred for palliative care, expiring soon thereafter.

Kramer (Am J Psychiatry. 1985;142:1190–1192 and J ECT. 1999;15:245–251) has reviewed the use of ECT in California from 1977 to 1983, and then again from 1984 to 1994. In both studies, he found that about 3% of the total cases were given to patients who could not provide an informed consent. In California, current mental health law mandates unanimous agreement of 3 psychiatrists before a hearing in front of a Superior Court judge can be scheduled. If it is determined that the patient is unable to consent, a surrogate decision maker is assigned. In our case, it took 14 days to obtain a court order assigning a surrogate decision maker, after which we were able to proceed with ECT. Given the patient’s debilitated state, earlier intervention with effective treatment may have altered the final outcome. Mental health laws are designed to protect patients from unnecessary and unwanted care. However, in the case of imminently life-threatening situations such as catatonia, there is a need for a mechanism to expedite obtaining consent.


  • 1. Kramer BA. Use of ECT in California, 1977–1983. Am J Psychiatry. 1985;142:1190–1192.
  • 2. Kramer BA. Use of ECT in California, Revisited: 1984–1994. J ECT. 1999;15:245–251.
  • 3. Parry B. The tragedy of legal impediments involved in obtaining ECT for patients unable to give informed consent. Am J Psychiatry. 1981;138:1128.

Transcranial Magnetic Stimulation for Depression Associated With Cocaine Addiction A Case Series

Marina Odebrecht Rosa, Guilherme Lozi Abdo, Moacyr Alexandro Rosa Rua Vergueiro, 1855 cj. 46 Sao Paulo, SP, Brazil.

Objective: The aim of this study was to evaluate the effects of rTMS in the treatment of patients with comorbid depression and drug addiction (cocaine).

Background: rTMS is already a very useful clinical tool for the treatment of depression. Its efficacy for other disorders is under intense investigation. Drug addiction is frequently comorbid with depressive illness, and its treatment involves a combination of medication, psychotherapy, and psychoeducation. rTMS is being investigated as a means of reducing craving among drug abusers. So, for comorbidity depression/addiction, rTMS may be useful for both.

Methods: Patients with depression (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) and cocaine addiction were included and received daily sessions of rTMS over the left dorsolateral prefrontal cortex (F3 point of the 10/20 EEG system; intensity, 100% of motor threshold; frequency, 10 Hz; train duration, 10 seconds; intertrain interval, 20 seconds; number of pulses per session, 6000). A neuro-MS stimulator was used.

Results: Eleven patients were included. They received a mean (SD) of 13 (4) rTMS sessions. All were men (mean age [SD], 33.3 [7.4] years). The mean (SD) Beck Inventory for Depression scores were 29.2 (5.2) at baseline and 6.2 (5.6) at the end of treatment. Drug craving was relieved in all patients during the course of the treatment.

Conclusions: rTMS was very efficacious for the treatment of depression and cocaine addiction in this population. This might be due to a synergistic effect on both depressive symptoms and possibly a direct effect on craving symptoms.

Resolution of Childhood Onset Attention Deficit Hyperactivity Disorder After Electroconvulsive Therapy for Major Depression in Adolescence

M. Justin Coffey, MD, Kelly M. Rogalski, MD

We describe the resolution of childhood onset attention-deficit/hyperactivity disorder (ADHD) after electroconvulsive therapy (ECT) for major depression in adolescence.

Case Report: A 16-year-old right-handed male patient was referred for ECT by his pediatric psychiatrist who had diagnosed a major depressive episode not responsive to adequate trials of fluoxetine, venlafaxine, and cognitive behavior therapy. The illness severity led to his withdrawing from school, abusing illicit drugs, and attempting suicide. With his mother’s fully informed consent and his assent, he completed an index course of bifrontal brief pulse ECT that was without complication. He discontinued all medications before commencing ECT. The depression fully remitted, and remission was sustained over the next 2 years during a course of continuation maintenance ECT.

The patient’s only other health problem was combined type ADHD first diagnosed by a pediatric psychiatrist when the patient was in second grade. A school-based neuropsychological evaluation supported the diagnosis. His symptoms responded to psychostimulant medication, which he continued into adolescence. After the index course of ECT, he experienced no recurrence of ADHD symptoms and was prescribed no treatment. He reentered school, graduated, and entered college. Ultimately, 18 months after he began ECT, his pediatric psychiatrist concluded that he no longer met diagnostic criteria for ADHD and removed it from his problem list.

Discussion: Although ADHD does not represent an indication for ECT, this case demonstrates the profound effect of ECT in an adolescent with ADHD and a comorbid mood disorder.

Somatoform Disorders Responsive to Electroconvulsive Therapy A Case Report and Literature Review

Davin Quinn, MD

Objective: The aim of this study was to report a case of a somatoform disorder without associated depressive symptoms responsive to electroconvulsive therapy (ECT) and to review the literature on this topic.

Background: The 2004 CORE study found somatization to predict poor response to electroconvulsive therapy (ECT) when not accompanied by severe depression. However, ECT has been reported as effective in several cases of somatoform presentations.

Methods: The authors report a case of a 72-year-old woman with a history of major depressive disorder who presented with complete anorexia due to unexplained abdominal pain associated with all oral intake. The literature on somatoform presentations responsive to ECT is reviewed.

Results: Workup for organic causes of the patient’s abdominal symptom was negative. Depression, catatonia, and psychosis were absent. Right unilateral ECT was initiated for a total of 12 treatments with complete resolution of the patient’s abdominal pain by series’ end. Between 1988 and 2014, there were 19 cases of somatoform disorders (excluding chronic pain) that responded to ECT. Major depressive disorder was present in 9 of 19, whereas 3 of 19 had no other psychiatric comorbidity. Theories explaining the benefit of ECT for select cases of psychogenic somatic symptoms include the presence of “masked depression” and changes in regional brain perfusion.

Conclusions: Although somatic delusions frequently accompany melancholic depressions and schizophrenia, primary somatoform disorders responsive to ECT are much rarer. Electroconvulsive therapy may be considered in the treatment of severe somatoform disorders, particularly when major depression is comorbid.

© 2014 by Lippincott Williams & Wilkins