Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy
Harold A Sackeim, Joan Prudic, Mitchell S Nobler, Linda Fitzsimons, Sarah H Lisanby, Nancy Payne, Robert M Berman, Eva-Lotta Brakemeier, Tarique Perera, D P Devanand, Harold A Sackeim, Joan Prudic, Mitchell S Nobler, Linda Fitzsimons, Sarah H Lisanby, Nancy Payne, Robert M Berman, Eva-Lotta Brakemeier, Tarique Perera, D P Devanand
Abstract
Background: While electroconvulsive therapy (ECT) in major depression is effective, cognitive effects limit its use. Reducing the width of the electrical pulse and using the right unilateral electrode placement may decrease adverse cognitive effects, while preserving efficacy.
Methods: In a double-masked study, we randomly assigned 90 depressed patients to right unilateral ECT at 6 times seizure threshold or bilateral ECT at 2.5 times seizure threshold, using either a traditional brief pulse (1.5 ms) or an ultrabrief pulse (0.3 ms). Depressive symptoms and cognition were assessed before, during, and immediately, two, and six months after therapy. Patients who responded were followed for a one-year period.
Results: The final remission rate for ultrabrief bilateral ECT was 35 percent, compared with 73 percent for ultrabrief unilateral ECT, 65 percent for standard pulse width bilateral ECT, and 59 percent for standard pulse width unilateral ECT (all P's<0.05 after covariate adjustment). The ultrabrief right unilateral group had less severe cognitive side effects than the other 3 groups in virtually all primary outcome measures assessed in the acute postictal period, and during and immediately following therapy. Both the ultrabrief stimulus and right unilateral electrode placement produced less short- and long-term retrograde amnesia. Patients rated their memory deficits as less severe following ultrabrief right unilateral ECT compared to each of the other three conditions (P<0.001).
Conclusions: The use of an ultrabrief stimulus markedly reduces adverse cognitive effects, and when coupled with markedly suprathreshold right unilateral ECT, also preserves efficacy. (ClinicalTrials.gov number, NCT00487500.).
Keywords: Depression; Efficacy; Electrical Stimulation; Electroconvulsive Therapy; Side Effects.
Figures
![Figure 1](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/2742986/bin/nihms79234f1.jpg)
![Figure 2](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/2742986/bin/nihms79234f2.jpg)
Figure 3
Scores on the Hamilton Rating…
Figure 3
Scores on the Hamilton Rating Scale for Depression Before, During and Following the…
Figure 4
Kaplan–Meier Estimates of the Proportion…
Figure 4
Kaplan–Meier Estimates of the Proportion of Patients Who Remained Well One Year after…
Figure 5
Scores on the Columbia University…
Figure 5
Scores on the Columbia University Autobiographical Memory Interview. Retrograde amnesia for autographical events…
- From Meduna to ultrabrief: New directions for the oldest brain stimulation therapy.Lerer B, Isserles M. Lerer B, et al. Brain Stimul. 2008 Apr;1(2):84-5. doi: 10.1016/j.brs.2008.03.005. Epub 2008 Apr 16. Brain Stimul. 2008. PMID: 20633372 No abstract available.
- Some brief thoughts on brief and ultra-brief pulse ECT.Coffey CE. Coffey CE. Brain Stimul. 2008 Apr;1(2):86-7. doi: 10.1016/j.brs.2008.03.002. Epub 2008 Apr 7. Brain Stimul. 2008. PMID: 20633373 No abstract available.
- Brief thoughts on ECT parameter settings.McIntyre C. McIntyre C. Brain Stimul. 2008 Apr;1(2):88. doi: 10.1016/j.brs.2008.03.004. Epub 2008 Apr 7. Brain Stimul. 2008. PMID: 20633374 No abstract available.
- Efficacy and cognitive side effects after brief pulse and ultrabrief pulse right unilateral electroconvulsive therapy for major depression: a randomized, double-blind, controlled study.Spaans HP, Verwijk E, Comijs HC, Kok RM, Sienaert P, Bouckaert F, Fannes K, Vandepoel K, Scherder EJ, Stek ML, Kho KH. Spaans HP, et al. J Clin Psychiatry. 2013 Nov;74(11):e1029-36. doi: 10.4088/JCP.13m08538. J Clin Psychiatry. 2013. PMID: 24330903 Clinical Trial.
- Cognitive effects of brief and ultrabrief pulse bitemporal electroconvulsive therapy: a randomised controlled proof-of-concept trial.Martin D, Katalinic N, Hadzi-Pavlovic D, Ingram A, Ingram N, Simpson B, McGoldrick J, Dowling N, Loo C. Martin D, et al. Psychol Med. 2020 May;50(7):1121-1128. doi: 10.1017/S0033291719000989. Epub 2019 May 2. Psychol Med. 2020. PMID: 31056081 Clinical Trial.
- Autobiographical and subjective memory with right unilateral high-dose 0.3-millisecond ultrabrief-pulse and 1-millisecond brief-pulse electroconvulsive therapy: a double-blind, randomized controlled trial.Mayur P, Byth K, Harris A. Mayur P, et al. J ECT. 2013 Dec;29(4):277-82. doi: 10.1097/YCT.0b013e3182941baf. J ECT. 2013. PMID: 24263273 Clinical Trial.
- Neurocognitive effects after brief pulse and ultrabrief pulse unilateral electroconvulsive therapy for major depression: a review.Verwijk E, Comijs HC, Kok RM, Spaans HP, Stek ML, Scherder EJ. Verwijk E, et al. J Affect Disord. 2012 Nov;140(3):233-43. doi: 10.1016/j.jad.2012.02.024. Epub 2012 May 15. J Affect Disord. 2012. PMID: 22595374 Review.
- Efficacy of ultrabrief pulse electroconvulsive therapy for depression: a systematic review.Spaans HP, Kho KH, Verwijk E, Kok RM, Stek ML. Spaans HP, et al. J Affect Disord. 2013 Sep 25;150(3):720-6. doi: 10.1016/j.jad.2013.05.072. Epub 2013 Jun 19. J Affect Disord. 2013. PMID: 23790557 Review.
- Electroconvulsive therapy-a shocking inducer of neuroplasticity?Tartt AN, Mariani M, Hen R, Mann JJ, Boldrini M. Tartt AN, et al. Mol Psychiatry. 2023 Mar 3. doi: 10.1038/s41380-023-02015-0. Online ahead of print. Mol Psychiatry. 2023. PMID: 36869226 No abstract available.
- Trajectories of Efficacy and Cognitive Function During Electroconvulsive Therapy Course in Young Adults with Treatment-Resistant Depression.Xu SX, Xie XH, Yao L, Chen LC, Wan Q, Chen ZH, Liu Z. Xu SX, et al. Neuropsychiatr Dis Treat. 2023 Jan 29;19:267-281. doi: 10.2147/NDT.S394155. eCollection 2023. Neuropsychiatr Dis Treat. 2023. PMID: 36744206 Free PMC article.
- Comparative efficacy, cognitive effects and acceptability of electroconvulsive therapies for the treatment of depression: protocol for a systematic review and network meta-analysis.Nikolin S, Owens K, Francis-Taylor R, Chaimani A, Martin DM, Bull M, Sackeim HA, McLoughlin DM, Sienaert P, Kellner CH, Loo C. Nikolin S, et al. BMJ Open. 2022 Dec 22;12(12):e068313. doi: 10.1136/bmjopen-2022-068313. BMJ Open. 2022. PMID: 36549738 Free PMC article.
- Links between electroconvulsive therapy responsive and cognitive impairment multimodal brain networks in late-life major depressive disorder.Qi S, Calhoun VD, Zhang D, Miller J, Deng ZD, Narr KL, Sheline Y, McClintock SM, Jiang R, Yang X, Upston J, Jones T, Sui J, Abbott CC. Qi S, et al. BMC Med. 2022 Dec 8;20(1):477. doi: 10.1186/s12916-022-02678-6. BMC Med. 2022. PMID: 36482369 Free PMC article.
- The Use of ECT in the Elderly-Looking Beyond Depression.Chatham AN, Shafi H, Hermida AP. Chatham AN, et al. Curr Psychiatry Rep. 2022 Sep;24(9):451-461. doi: 10.1007/s11920-022-01353-0. Epub 2022 Jul 13. Curr Psychiatry Rep. 2022. PMID: 35829850 Review.
- Randomized Controlled Trial
- Research Support, N.I.H., Extramural
- Adult
- Aged
- Cognition / physiology*
- Depressive Disorder, Major / physiopathology
- Depressive Disorder, Major / prevention & control
- Depressive Disorder, Major / therapy*
- Double-Blind Method
- Electroconvulsive Therapy* / adverse effects
- Electroconvulsive Therapy* / instrumentation
- Electroconvulsive Therapy* / methods
- Electrodes*
- Female
- Humans
- Memory Disorders / etiology*
- Middle Aged
- Neuropsychological Tests
- Prospective Studies
- Recurrence
- Research Design
- Treatment Outcome
- ClinicalTrials.gov/NCT00487500
- Full Text Sources
- Other Literature Sources
- Medical
NCBI Literature Resources
The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.
National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
![Figure 3](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/2742986/bin/nihms79234f3.jpg)
Figure 4
Kaplan–Meier Estimates of the Proportion…
Figure 4
Kaplan–Meier Estimates of the Proportion of Patients Who Remained Well One Year after…
Figure 5
Scores on the Columbia University…
Figure 5
Scores on the Columbia University Autobiographical Memory Interview. Retrograde amnesia for autographical events…
- From Meduna to ultrabrief: New directions for the oldest brain stimulation therapy.Lerer B, Isserles M. Lerer B, et al. Brain Stimul. 2008 Apr;1(2):84-5. doi: 10.1016/j.brs.2008.03.005. Epub 2008 Apr 16. Brain Stimul. 2008. PMID: 20633372 No abstract available.
- Some brief thoughts on brief and ultra-brief pulse ECT.Coffey CE. Coffey CE. Brain Stimul. 2008 Apr;1(2):86-7. doi: 10.1016/j.brs.2008.03.002. Epub 2008 Apr 7. Brain Stimul. 2008. PMID: 20633373 No abstract available.
- Brief thoughts on ECT parameter settings.McIntyre C. McIntyre C. Brain Stimul. 2008 Apr;1(2):88. doi: 10.1016/j.brs.2008.03.004. Epub 2008 Apr 7. Brain Stimul. 2008. PMID: 20633374 No abstract available.
- Efficacy and cognitive side effects after brief pulse and ultrabrief pulse right unilateral electroconvulsive therapy for major depression: a randomized, double-blind, controlled study.Spaans HP, Verwijk E, Comijs HC, Kok RM, Sienaert P, Bouckaert F, Fannes K, Vandepoel K, Scherder EJ, Stek ML, Kho KH. Spaans HP, et al. J Clin Psychiatry. 2013 Nov;74(11):e1029-36. doi: 10.4088/JCP.13m08538. J Clin Psychiatry. 2013. PMID: 24330903 Clinical Trial.
- Cognitive effects of brief and ultrabrief pulse bitemporal electroconvulsive therapy: a randomised controlled proof-of-concept trial.Martin D, Katalinic N, Hadzi-Pavlovic D, Ingram A, Ingram N, Simpson B, McGoldrick J, Dowling N, Loo C. Martin D, et al. Psychol Med. 2020 May;50(7):1121-1128. doi: 10.1017/S0033291719000989. Epub 2019 May 2. Psychol Med. 2020. PMID: 31056081 Clinical Trial.
- Autobiographical and subjective memory with right unilateral high-dose 0.3-millisecond ultrabrief-pulse and 1-millisecond brief-pulse electroconvulsive therapy: a double-blind, randomized controlled trial.Mayur P, Byth K, Harris A. Mayur P, et al. J ECT. 2013 Dec;29(4):277-82. doi: 10.1097/YCT.0b013e3182941baf. J ECT. 2013. PMID: 24263273 Clinical Trial.
- Neurocognitive effects after brief pulse and ultrabrief pulse unilateral electroconvulsive therapy for major depression: a review.Verwijk E, Comijs HC, Kok RM, Spaans HP, Stek ML, Scherder EJ. Verwijk E, et al. J Affect Disord. 2012 Nov;140(3):233-43. doi: 10.1016/j.jad.2012.02.024. Epub 2012 May 15. J Affect Disord. 2012. PMID: 22595374 Review.
- Efficacy of ultrabrief pulse electroconvulsive therapy for depression: a systematic review.Spaans HP, Kho KH, Verwijk E, Kok RM, Stek ML. Spaans HP, et al. J Affect Disord. 2013 Sep 25;150(3):720-6. doi: 10.1016/j.jad.2013.05.072. Epub 2013 Jun 19. J Affect Disord. 2013. PMID: 23790557 Review.
- Electroconvulsive therapy-a shocking inducer of neuroplasticity?Tartt AN, Mariani M, Hen R, Mann JJ, Boldrini M. Tartt AN, et al. Mol Psychiatry. 2023 Mar 3. doi: 10.1038/s41380-023-02015-0. Online ahead of print. Mol Psychiatry. 2023. PMID: 36869226 No abstract available.
- Trajectories of Efficacy and Cognitive Function During Electroconvulsive Therapy Course in Young Adults with Treatment-Resistant Depression.Xu SX, Xie XH, Yao L, Chen LC, Wan Q, Chen ZH, Liu Z. Xu SX, et al. Neuropsychiatr Dis Treat. 2023 Jan 29;19:267-281. doi: 10.2147/NDT.S394155. eCollection 2023. Neuropsychiatr Dis Treat. 2023. PMID: 36744206 Free PMC article.
- Comparative efficacy, cognitive effects and acceptability of electroconvulsive therapies for the treatment of depression: protocol for a systematic review and network meta-analysis.Nikolin S, Owens K, Francis-Taylor R, Chaimani A, Martin DM, Bull M, Sackeim HA, McLoughlin DM, Sienaert P, Kellner CH, Loo C. Nikolin S, et al. BMJ Open. 2022 Dec 22;12(12):e068313. doi: 10.1136/bmjopen-2022-068313. BMJ Open. 2022. PMID: 36549738 Free PMC article.
- Links between electroconvulsive therapy responsive and cognitive impairment multimodal brain networks in late-life major depressive disorder.Qi S, Calhoun VD, Zhang D, Miller J, Deng ZD, Narr KL, Sheline Y, McClintock SM, Jiang R, Yang X, Upston J, Jones T, Sui J, Abbott CC. Qi S, et al. BMC Med. 2022 Dec 8;20(1):477. doi: 10.1186/s12916-022-02678-6. BMC Med. 2022. PMID: 36482369 Free PMC article.
- The Use of ECT in the Elderly-Looking Beyond Depression.Chatham AN, Shafi H, Hermida AP. Chatham AN, et al. Curr Psychiatry Rep. 2022 Sep;24(9):451-461. doi: 10.1007/s11920-022-01353-0. Epub 2022 Jul 13. Curr Psychiatry Rep. 2022. PMID: 35829850 Review.
- Randomized Controlled Trial
- Research Support, N.I.H., Extramural
- Adult
- Aged
- Cognition / physiology*
- Depressive Disorder, Major / physiopathology
- Depressive Disorder, Major / prevention & control
- Depressive Disorder, Major / therapy*
- Double-Blind Method
- Electroconvulsive Therapy* / adverse effects
- Electroconvulsive Therapy* / instrumentation
- Electroconvulsive Therapy* / methods
- Electrodes*
- Female
- Humans
- Memory Disorders / etiology*
- Middle Aged
- Neuropsychological Tests
- Prospective Studies
- Recurrence
- Research Design
- Treatment Outcome
- ClinicalTrials.gov/NCT00487500
- Full Text Sources
- Other Literature Sources
- Medical
![Figure 4](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/2742986/bin/nihms79234f4.jpg)
![Figure 5](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/2742986/bin/nihms79234f5.jpg)
Source: PubMed