Bitemporal Versus High-Dose Unilateral Twice-Weekly Electroconvulsive Therapy for Depression (EFFECT-Dep): A Pragmatic, Randomized, Non-Inferiority Trial.

OBJECTIVE: ECT is the most effective treatment for severe depression. Previous efficacy studies, using thrice-weekly brief-pulse ECT, reported that high-dose (6× seizure threshold) right unilateral ECT is similar to bitemporal ECT but may have fewer cognitive side effects. The authors aimed to assess the effectiveness and cognitive side effects of twice-weekly moderate-dose (1.5× seizure threshold) bitemporal ECT with high-dose unilateral ECT in real-world practice. METHOD: This was a pragmatic, patient- and rater-blinded, noninferiority trial of patients with major depression (N=138; 63% female; age=56.7 years [SD=14.8]) in a national ECT service with a 6-month follow-up. Participants were independently randomly assigned to bitemporal or high-dose unilateral ECT. The primary outcome was change in the 24-item Hamilton Depression Rating Scale (HAM-D) score after the ECT course; the prespecified noninferiority margin was 4.0 points. Secondary outcomes included response and remission rates, relapse status after 6 months, and cognition. RESULTS: Of the eligible patients, 69 were assigned to bitemporal ECT and 69 to unilateral ECT. High-dose unilateral ECT was noninferior to bitemporal ECT regarding the 24-item HAM-D scores after the ECT course (mean difference=1.08 points in favor of unilateral ECT [95% CI=-1.67 to 3.84]). There were no significant differences for response and remission or 6-month relapse status. Recovery of orientation was quicker following unilateral ECT (median=19.1 minutes versus 26.4 minutes). Bitemporal ECT was associated with a lower percent recall of autobiographical information (odds ratio=0.66) that persisted for 6 months. CONCLUSIONS: Twice-weekly high-dose unilateral ECT is not inferior to bitemporal ECT for depression and may be preferable because of its better cognitive side-effect profile.

Impaired auditory selective attention ameliorated by cognitive training with graded exposure to noise in patients with traumatic brain injury.

Patients who suffer traumatic brain injury frequently report difficulty concentrating on tasks and completing routine activities in noisy and distracting environments. Such impairments can have long-term negative psychosocial consequences. A cognitive control function that may underlie this impairment is the capacity to select a goal-relevant signal for further processing while safeguarding it from irrelevant noise. A paradigmatic investigation of this problem was undertaken using a dichotic listening task (study 1) in which comprehension of a stream of speech to one ear was measured in the context of increasing interference from a second stream of irrelevant speech to the other ear. Controls showed an initial decline in performance in the presence of competing speech but thereafter showed adaptation to increasing audibility of irrelevant speech, even at the highest levels of noise. By contrast, patients showed linear decline in performance with increasing noise. Subsequently attempts were made to ameliorate this deficit (study 2) using a cognitive training procedure based on attention process training (APT) that included graded exposure to irrelevant noise over the course of training. Patients were assigned to adaptive and non-adaptive training schedules or to a no-training control group. Results showed that both types of training drove improvements in the dichotic listening and in naturalistic tasks of performance in noise. Improvements were also seen on measures of selective attention in the visual domain suggesting transfer of training. We also observed augmentation of event-related potentials (ERPs) linked to target processing (P3b) but no change in ERPs evoked by distractor stimuli (P3a) suggesting that training heightened tuning of target signals, as opposed to gating irrelevant noise. No changes in any of the above measures were observed in a no-training control group. Together these findings present an ecologically valid approach to measure selective attention difficulties after brain injury, and provide a means to ameliorate these deficits.

Construction and updating of a public events questionnaire for repeated measures longitudinal studies.

Impairments of retrospective memory and cases of retrograde amnesia are often seen in clinical settings. A measure of the proportion of memories retained over a specified time can be useful in clinical situations and public events questionnaires may be valuable in this respect. However, consistency of retention of public events memory has rarely been studied in the same participants. In addition, when used in a research context, public events questionnaires require updating to ensure questions are of equivalent age with respect to when the test is taken. This paper describes an approach to constructing and updating a Public Events Questionnaire (PEQ) for use with a sample that is recruited and followed-up over a long time-period. Internal consistency, parallel-form reliability, test-retest reliability, and secondary validity analyses were examined for three versions of the PEQ that were updated every 6 months. Versions 2 and 3 of the questionnaire were reliable across and within versions and for recall and recognition. Change over time was comparable across each version of the PEQ. These results show that PEQs can be regularly updated in a standardized fashion to allow use throughout studies with long recruitment periods.

Measuring consistency of autobiographical memory recall in depression.

Autobiographical amnesia assessments in depression need to account for normal changes in consistency over time, contribution of mood and type of memories measured. We report herein validation studies of the Columbia Autobiographical Memory Interview - Short Form (CAMI-SF), exclusively used in depressed patients receiving electroconvulsive therapy (ECT) but without previous published report of normative data. The CAMI-SF was administered twice with a 6-month interval to 44 healthy volunteers to obtain normative data for retrieval consistency of its Semantic, Episodic-Extended and Episodic-Specific components and assess their reliability and validity. Healthy volunteers showed significant large decreases in retrieval consistency on all components. The Semantic and Episodic-Specific components demonstrated substantial construct validity. We then assessed CAMI-SF retrieval consistencies over a 2-month interval in 30 severely depressed patients never treated with ECT compared with healthy controls (n=19). On initial assessment, depressed patients produced less episodic-specific memories than controls. Both groups showed equivalent amounts of consistency loss over a 2-month interval on all components. At reassessment, only patients with persisting depressive symptoms were distinguishable from controls on episodic-specific memories retrieved. Research quantifying retrograde amnesia following ECT for depression needs to control for normal loss in consistency over time and contribution of persisting depressive symptoms.