The influence of concomitant antidepressant medication on safety, tolerability and clinical effectiveness of electroconvulsive therapy.

BACKGROUND: A major problem in the treatment of severe depression is the onset latency until clinical improvement. So far, electroconvulsive therapy (ECT) is the most effective somatic treatment of depression. This holds especially true for treatment-refractory disturbances. However, not all patients respond to conventional unilateral ECT. In certain cases, subsequent clinical response can be achieved using bilateral or high-dose unilateral ECT. Also, a concomitant pharmacotherapy can be utilized to augment therapeutic effectiveness. Surprisingly, data in this field are widely lacking and only few studies showed advantages of an ECT/tricyclic antidepressant combination. METHOD: We retrospectively evaluated 5482 treatments in 455 patients to investigate possible therapeutic advantages in combination therapies versus ECT monotherapy. Main outcome criteria were clinical effectiveness and tolerability. Moreover, treatment modalities and ictal neurophysiological parameters that might influence treatment outcome were analysed. RESULTS: A total of 18.2% of our treatments were ECT monotherapy, 8.87% were done with one antidepressant. Seizure duration was unaffected by the most antidepressants. SSRI caused a lengthened seizure activity. Postictal suppression was lower in mirtazapine and higher in SSRI and SNRI treated patients. A significant enhancement of therapeutic effectiveness could be seen in the patient group receiving tricyclics, SSRI or mirtazapine. Serious adverse events were not recorded. CONCLUSION: Our study supports the hypothesis that mirtazapine can be used to enhance the therapeutic effectiveness of ECT. Controlled studies are necessary to further investigate the possible advantages of ECT and pharmacotherapy combinations, especially the use of modern dually acting antidepressants which have proven their good effectiveness in treatment-resistant depression.

The influence of anaesthetic medication on safety, tolerability and clinical effectiveness of electroconvulsive therapy.

BACKGROUND: Electroconvulsive therapy (ECT) is still considered the most effective biological treatment strategy in psychiatric disorders. However, the clinical efficacy of ECT may be affected by stimulus variables and the concomitant use of psychopharmacological medication. Furthermore, most anaesthetics have anticonvulsant properties and therefore might additionally influence the efficacy of ECT. METHOD: In order to explore whether different anaesthetics might alter the effectiveness or safety of ECT we retrospectively analyzed 5482 ECT treatments in 455 patients. Anaesthetics were chosen according to clinical reasons and comprised thiopental, methohexital, propofol and etomidate. RESULTS: Seizure duration was significantly affected by the anaesthetic medication with longest seizure activity during thiopental anaesthesia. In addition, postictal suppression, a further prospective parameter of ECT effectiveness, was significantly higher during propofol and thiopental anaesthesia. The clinical effectiveness was significantly better during propofol and thiopental anaesthesia. In contrast, the overall safety did not differ between the anaesthetic groups. CONCLUSION: Our study supports the hypothesis that inducting anaesthetic agents have a different impact on seizure duration, ictal and postictal electrophysiological indices and clinical efficacy of ECT. Compared to thiopental, which has been established as a standard anaesthetic during ECT, also the modern anaesthetic propofol is a suitable inducting agent.