Original Article
Effects of Stimulus Intensity and Electrode Placement on the Efficacy and Cognitive Effects of Electroconvulsive Therapy
N Engl J Med 1993; 328:839-846March 25, 1993
- Abstract
Background
The efficacy of electroconvulsive therapy in major depression is established, but the importance of the electrical dosage and electrode placement in relation to efficacy and side effects is uncertain.
Methods
In a double-blind study, we randomly assigned 96 depressed patients to receive right unilateral or bilateral electroconvulsive therapy at either a low electrical dose (just above the seizure threshold) or a high dose (2.5 times the threshold). Symptoms of depression and cognitive functioning were assessed before, during, immediately after, and two months after therapy. Patients who responded to treatment were followed for one year to assess the rate of relapse.
Results
The response rate for low-dose unilateral electroconvulsive therapy was 17 percent, as compared with 43 percent for high-dose unilateral therapy (P = 0.054), 65 percent for low-dose bilateral therapy (P = 0.001), and 63 percent for high-dose bilateral therapy (P = 0.001). Regardless of electrode placement, high dosage resulted in more rapid improvement (P<0.05). Compared with the low-dose unilateral group, the high-dose unilateral group took 83 percent longer (P<0.001) to recover orientation after seizure induction, whereas the combined bilateral groups took 252 percent longer (P<0.001). During the week after treatment, there was three times more retrograde amnesia about personal information with bilateral therapy (P<0.001). There were no differences between treatment groups in cognitive effects two months after treatment. Forty-one of the 70 patients who responded to therapy (59 percent) relapsed, and there were no differences between treatment groups.
Conclusions
Increasing the electrical dosage increases the efficacy of right unilateral electroconvulsive therapy, although not to the level of bilateral therapy. High electrical dosage is associated with a more rapid response, and unilateral treatment is associated with less severe cognitive side effects after treatment. .
Media in This Article
Figure 1
Mean Scores on the Hamilton Rating Scale for Depression at Base Line, after Six Treatments, Immediately after the Last Treatment, and One Week after the Last Treatment in the Four Groups.Figure 2
Kaplan-Meier Estimates of the Proportion of Patients Who Remained Well One Year after Electroconvulsive Therapy, According to Treatment Group.Article Activity
- Article
Electroconvulsive therapy is widely used to treat certain psychiatric disorders, particularly major depression1,2. For the past 30 years, its practitioners have thought that a generalized seizure of adequate duration is necessary and sufficient for antidepressant effects1,3,4 and that the intensity of the electrical stimulus contributes to decreased cognitive function, the principal side effect, but not to efficacy. Modifications of the technique, introduced to minimize cognitive side effects while maintaining efficacy, have included the use of unilateral electrode placement and the adjustment of stimulus intensity to the seizure threshold of each patient2,5,6.
Positioning electrodes over the right hemisphere causes less severe cognitive side effects than bilateral placement7,8. Despite many trials, however, the relative efficacy of right unilateral and bilateral electroconvulsive therapy is controversial2,9,10. Some studies have found superior efficacy with bilateral therapy,11-13 whereas others have reported equivalent efficacy14-16. Given this uncertainty, the American Psychiatric Association Task Force on Electroconvulsive Therapy recently recommended that electrode placement be determined on a case-by-base basis2.
Until recently, the standard practice has been to administer the same electrical dose to virtually all patients. Among patients, however, the seizure threshold, defined as the minimal electrical intensity needed for a generalized seizure of a specified minimal duration, appears to vary by approximately 40-fold6,17. When a fixed dose is used, many patients receive stimulation grossly above the threshold, and cognitive side effects are probably increased2,18,19.
In a study using an electrical intensity just above each patient's seizure threshold, we found that titrated, low-dose bilateral electroconvulsive therapy had a powerful antidepressant effect but that low-dose right unilateral therapy was ineffective13. These results led to the hypothesis that the efficacy of right unilateral electroconvulsive therapy depends on the electrical dose20,21. Other research has raised the possibility that for both unilateral and bilateral electroconvulsive therapy, a higher electrical dose leads to a more rapid clinical response3,16,22. We report a prospective, randomized, double-blind trial of the effects of both stimulus intensity and electrode placement on the efficacy and safety of electroconvulsive therapy in 96 patients.
Methods
Patients
The study patients met the Research Diagnostic Criteria23 for major depressive disorder, had pretreatment scores of 18 or higher on the 24-item Hamilton Rating Scale for Depression (HRSD),24 and gave written informed consent. All had clinical indications for electroconvulsive therapy that included a lack of response to previous treatment with antidepressant medication, intolerance to such medication, a particular need for a rapid clinical response due to conditions such as inanition, psychosis, or suicidality, or a history of clinical response to electroconvulsive therapy2. Patients were excluded if they had a history of schizophrenia, schizoaffective disorder, other functional psychosis, rapid-cycling bipolar illness, organic mental syndrome, neurologic illness, alcohol or other drug abuse within the previous year, electroconvulsive therapy within the previous six months, or severe medical illness. All the patients had normal results of routine hematologic and biochemical tests, including thyroid-function tests, chest roentgenography, and electroencephalography. The 31 patients who had computed tomography or magnetic resonance imaging of the brain all had normal findings. All the patients were inpatients at the New York State Psychiatric Institute, where the institutional review board approved the study.
Of 100 consecutive patients admitted to the study, 4 were considered to have dropped out because they received fewer than five treatments; the reasons were withdrawal of consent (1 patient), the need to institute concomitant psychotropic treatment (1 patient), and intercurrent illness (2 patients). With the exception of lorazepam (up to 3 mg of which was allowed per day), all psychotropic medications were discontinued at least 5 days (mean [±SD], 17 ±8; maximum, 30) before electroconvulsive therapy and until 1 week after the therapy had ended. The mean dose of lorazepam during electroconvulsive therapy was 1.0 ±1.0 mg per day and was similar in the four treatment groups.
Electroconvulsive Therapy
The patients were randomly assigned to treatment groups in blocks of 20. Atropine (0.4 mg), methohexital (0.75 mg per kilogram of body weight), and succinylcholine (0.5 mg per kilogram), all given intravenously, were used as the anesthetic medications. The standard bifrontotemporal (bilateral) placement and the d'Elia (right unilateral) placement5 of electrodes were used. Electroconvulsive therapy was administered three times per week with a square-wave, brief-pulse, constant-current device (MECTA, Lake Oswego, Oreg.). The seizure threshold was quantified at the time of the first and last treatments with the empirical titration procedure2,6. Electrical stimulations were administered at subconvulsive levels of increasingly higher intensity until a generalized tonic-clonic seizure of adequate duration was induced. For low-dose treatment, the electrical intensity that resulted in a generalized seizure in the first session was the one administered at the next treatment. If this intensity proved adequate, a lower intensity was used for the next treatment. In the low-dose groups, this procedure was followed throughout the treatment course. For high-dose treatment, at the second and subsequent treatments each patient received stimulation of an electrical intensity that in units of charge was 2.5 times the threshold identified in the first treatment, except that at the time of the last treatment the seizure threshold was determined again. The frequency of brief pulses (range, 20 to 140 Hz) was the primary electrical variable manipulated, because the device used for electroconvulsive therapy had greater range and sensitivity in the frequency domain than pulse width, current intensity, or the duration of the stimulus. The tourniquet method25 and two channels of prefrontal electroencephalography were used to assess the duration of seizures. In the first five treatments, the criterion for an adequate generalized seizure was at least 25 seconds of tonic-clonic movement or 30 seconds of electroencephalographic seizure activity. After the fifth treatment, the cutoff values were reduced to 20 and 25 seconds, respectively. This change was made to account for the spontaneous decrease in seizure duration that occurs during electroconvulsive therapy17.
Clinical Evaluations
The patients and the clinical evaluation team (a research psychiatrist and a social worker) were unaware of the treatment-group assignments. The team rated each patient on the HRSD two days before the first treatment, at least twice weekly during treatment, within two days after the end of treatment, and one week after the end of treatment. The interrater reliability coefficients for the HRSD scores exceeded 0.98 at all times. Analyses of these scores were based on the mean scores obtained by the raters.
The patients considered to have responded initially to therapy had a decrease of at least 60 percent in their HRSD scores from before treatment to immediately after the final treatment, and they had a maximal score of 16 after treatment. To be classified in the final analysis as having responded to therapy, patients had to maintain this level of improvement for at least one week after electroconvulsive therapy. No minimal or maximal number of treatments was imposed on patients who improved progressively. These patients continued to receive treatment until they were asymptomatic or had reached a plateau in clinical improvement after 2 consecutive treatments; they had a range of 4 to 17 treatments overall. At least 10 treatments were required before a patient was classified as not having responded, with 8 treatments required of patients who had reductions of 20 percent or less in HRSD scores during therapy. These patients then received a course of high-dose bilateral electroconvulsive therapy. The evaluation of efficacy during this crossover phase was made with the same procedures that were used in the randomized phase. Patients who responded to therapy during either phase were followed until relapse, as defined elsewhere,26 or for one year. Interviews to determine HRSD scores were conducted every two weeks for the first three months after electroconvulsive therapy and monthly thereafter. During the follow-up period, virtually all the patients received maintenance pharmacotherapy with antidepressant medications.
Cognitive Evaluations
Short-term neuropsychological effects were assessed at the time of each treatment during the randomized phase. Before each treatment, a 10-item interview evaluating the patient's orientation was administered. The patients then memorized sets of words, geometric shapes, nonsense shapes, and faces that were either neutral or emotionally expressive. After the presentation of each set, immediate learning was assessed by testing the patient's recall and recognition for the word task and by testing the patient's recognition for the shape and face tasks. After the seizure, the recovery of orientation was assessed continuously for 90 minutes. Patients who did not meet the criteria for the recovery of orientation7 were assigned scores of 100 minutes. Once the criteria were met, each patient's retrograde memory was tested for the material learned previously. Twelve equivalent sets of stimuli were available for each task, with the assignment randomized at the time of each treatment7.
Neuropsychological tests focusing on anterograde and retrograde memory were administered before the start of treatment, the day after some treatments, during the week after the end of the randomized and crossover phases, and two months later. The tests included modified versions of the Mini-Mental State Examination,27 recognition memory of paired words and paired faces,28 the Selective Reminding Test,29 and an expanded Autobiographical Memory Interview8. The paired-word and paired-face tasks assessed both immediate learning and memory after a four-hour delay. Recall after a two-hour delay was included in the Selective Reminding Test. Patients evaluated their own memory function by completing the Squire Subjective Memory Questionnaire30.
Statistical Analysis
The results are expressed as means ±SD. All statistical tests were two-tailed. Analyses of electrical variables and measures of seizure duration were performed on logarithmically transformed values, and arc-sine transformations were applied to scores reflecting percentages of change. The treatment groups were compared with respect to base-line measures with two-way analyses of variance for continuous variables and with log-linear analyses for dichotomous variables. As an omnibus test of short-term differences in efficacy, a multivariate analysis of covariance was conducted of the HRSD scores, with electrode placement and dosage condition as between-subject factors, time (before electroconvulsive therapy, after six treatments, immediately after treatment, and one week after treatment) as a repeated-measures factor, and the patient's age as a covariate. This was followed by analyses of covariance of the HRSD scores obtained at the most recent three time points, with age and HRSD scores before treatment used as covariates. Post hoc Newman-Keuls comparisons of covariate-adjusted means were used to identify pairwise group differences. Chi-square tests were used to compare rates of clinical response. To examine the speed of clinical response, the number of treatments required for reductions from base line of 40, 50, 60, and 70 percent in HRSD scores to be achieved was analyzed by analysis of variance. Multiple regression analyses were used to determine whether either the dosage relative to threshold or the absolute electrical dose administered contributed to efficacy. In these analyses, dosage (low or high) and mean absolute dose per treatment served as predictors of the percentage change in HRSD scores. Survival analyses, with both regression models and life-table methods, provided tests of differences between treatment groups with respect to the likelihood and speed of relapse. These analyses were conducted both with patients who responded to crossover treatment considered as a separate group and with these patients included in the group that had responded to high-dose bilateral electroconvulsive therapy. In the regression models, age and HRSD scores one week after electroconvulsive therapy were covariates.
Similar methods were used to examine how the conditions of treatment affected cognitive performance. For short-term measures of orientation recovery and retrograde memory, average scores were derived for each patient, with the first and last treatments excluded because they involved low dosages in all groups. Scores for the percentage of amnesia were computed by subtracting the scores for delayed learning from the scores for immediate learning and dividing the difference by the scores for immediate learning.
Results
Characteristics of Patients and Treatment Measures
The demographic and clinical characteristics of the treatment groups were similar (P>0.05 for each comparison) (Table 1Table 1
Demographic and Clinical Characteristics of the Patients at Study Entry, According to Treatment Group.). The doses of methohexital and succinylcholine and all the measures of seizure duration were also similar among all groups (Table 2Table 2
Measures of Electroconvulsive Therapy, According to Treatment Group.). In a replication of previous findings,6 the initial seizure threshold was higher in the patients treated with bilateral therapy than in those treated with right unilateral therapy. Consequently, the bilateral-therapy groups exceeded the unilateral-therapy groups, and the high-dose groups exceeded the low-dose groups, on all measures of stimulus intensity. The increase in seizure threshold during electroconvulsive therapy was greater with low-dose bilateral therapy than with low-dose unilateral therapy, resulting in a smaller proportional difference in charge between low-dose and high-dose groups when therapy was given bilaterally rather than unilaterally.Efficacy
Both electrode placement (P = 0.001) and electrical dosage (P = 0.005) strongly influenced clinical outcome (Figure 1Figure 1
Mean Scores on the Hamilton Rating Scale for Depression at Base Line, after Six Treatments, Immediately after the Last Treatment, and One Week after the Last Treatment in the Four Groups.). After the sixth treatment, the antidepressant response in the low-dose unilateral group was significantly worse than in the high-dose unilateral group (P = 0.01), the low-dose bilateral group (P<0.05), and the high-dose bilateral group (P<0.001). At this time, the HRSD score was higher in the low-dose bilateral group than in the high-dose bilateral group (P<0.05). Immediately after the end of treatment, the low-dose unilateral group also had a higher HRSD score than the other groups (P<0.01). One week after electroconvulsive therapy, the low-dose unilateral group continued to have a higher HRSD score than the high-dose unilateral group (P<0.05) and the two bilateral groups (P<0.001). At this time, the high-dose unilateral group had higher HRSD scores than the high-dose bilateral group (P<0.05).Only 22 percent of the low-dose unilateral group had an initial response to treatment (Table 3Table 3
Initial and Final Clinical Responses, Number of Treatments, and Early Termination, According to Treatment Group.), a lower rate than that in each of the other three treatment groups (P ≤ 0.001). The final response rate in the low-dose unilateral group (17 percent) was also lower than those in the high-dose unilateral group (43 percent, P = 0.054), the low-dose bilateral group (65 percent, P = 0.001), and the high-dose bilateral group (63 percent, P = 0.001). Early relapse (within one week) was most common in the high-dose unilateral group. The final response rate tended to be lower in this group than in the combined groups receiving bilateral electroconvulsive therapy (P = 0.099).Speed of Clinical Response
The low-dose unilateral group was excluded from the analyses of speed of response, since too few patients in this group had improvement. Except for the 70 percent improvement cutoff, the remaining three treatment groups differed in each analysis (P<0.05). Approximately 1.5 more treatments were administered in the low-dose bilateral group than in either of the high-dose groups in order to achieve reductions in HRSD scores of 40, 50, and 60 percent (P<0.05 for each comparison).
Absolute Electrical Dose or Dose Relative to Threshold
Among patients treated with right unilateral electroconvulsive therapy, improvement in symptoms was associated with dosage group after the sixth treatment (P = 0.008), immediately after treatment (P = 0.005), and one week later (P = 0.08). Clinical improvement was not related to the absolute electrical dose at any point. In the case of bilateral therapy, dosage group was associated with improvement after the sixth treatment (P = 0.007), but not after that point. Again, the absolute electrical dose had no relation with clinical outcome. Therefore, efficacy was influenced by whether the electrical dose exceeded the patient's seizure threshold, rather than by the absolute dose administered.
Crossover Phase
Of the 40 patients who did not respond to therapy and were not randomly assigned to high-dose bilateral therapy, 34 (85 percent) completed the crossover phase. They received 8.5 ±3.2 high-dose treatments bilaterally. Their HRSD scores were 35 ±9 before any treatment, 27 ±10 after the randomized phase, and 9 ±6 one week after the crossover phase; 79 percent were classified as having responded. Improvement in symptoms was equivalent regardless of the randomized assignment, and 12 of the 15 patients who had not responded to low-dose unilateral therapy (80 percent) responded after crossover treatment.
Relapse
Of the 73 patients who responded to randomized or crossover treatment (46 and 27 patients, respectively), 70 were followed for up to one year. Three patients declined to participate in monitoring for relapse and were lost to follow-up. The conditions in which electroconvulsive therapy was provided were unrelated to the likelihood or the speed of relapse (Figure 2Figure 2
Kaplan-Meier Estimates of the Proportion of Patients Who Remained Well One Year after Electroconvulsive Therapy, According to Treatment Group.). Forty-one of the 70 patients (59 percent) met the criteria for relapse; 78 percent of the relapses occurred within the first six months.Short-Term Cognitive Side Effects
Eight patients were excluded from short-term neuropsychological testing because they had visual or auditory deficits, difficulties with language, or impaired orientation at base line. At the postictal assessments, cognition was generally more impaired in the groups receiving bilateral or high-dose therapy (Table 4Table 4
Short-Term Effects Immediately after Electroconvulsive Therapy on Recovery of Orientation and Memory Functions, According to Treatment Group.). The rare instances of prolonged disorientation occurred exclusively with bilateral electroconvulsive therapy (P = 0.008). Time to the recovery of orientation was a function of electrode placement (P<0.001), electrical dosage (P = 0.001), and the interaction of the two (P = 0.03). The recovery of orientation took 83 percent longer (P<0.001) with high-dose unilateral electroconvulsive therapy than with low-dose unilateral therapy, whereas the combined bilateral-therapy groups took 252 percent longer (P<0.001). Bilateral therapy resulted in more profound amnesia than unilateral therapy with regard to the recall and recognition of words (P<0.001). Bilateral therapy and high dosage both resulted in more impaired performance on the shape tests and the test of emotionally expressive faces (P<0.05). For these tasks, the amnesia produced by high-dose unilateral electroconvulsive therapy exceeded that produced by low-dose unilateral therapy (P<0.05). For the cognitive measures that showed dosage effects, regression analyses indicated that dosage was the determining factor, rather than the absolute dose administered (data not shown).The treatment groups were equivalent at base line with respect to neuropsychological measures (Table 5Table 5
Short-Term Effects of Electroconvulsive Therapy on Cognitive Measures, According to Treatment Group.). Bilateral electroconvulsive therapy resulted in more impairment than did unilateral therapy on a variety of assessment measures during and immediately after treatment. These included orientation errors before each treatment (P = 0.002), scores on the Mini-Mental State Examination after the sixth session of electroconvulsive therapy (P = 0.009) and at the end of treatment (P<0.001), learning in the anterograde paired-words task after the seventh treatment (P = 0.006) and at the end of treatment (P<0.001) and forgetting scores in this task after the seventh treatment (P = 0.02) and at the end of treatment (P = 0.04), forgetting scores after treatment on the Selective Reminding Test (P = 0.006), and scores after treatment on the retrograde Autobiographical Memory Interview (P<0.001). The only effects involving dosage indicated that after treatment, forgetting in the paired-words task was particularly pronounced with high-dose bilateral electroconvulsive therapy (P = 0.04), and after the seventh treatment, learning in the paired-faces task was particularly impaired with high-dose unilateral therapy (P = 0.03).In contrast to the demonstrable objective cognitive deficits, the patients reported marked subjective improvement in their memory (43 ±65 percent improvement for all patients, P<0.001), and there were no significant differences between treatment groups (Table 5). The change in HRSD scores during treatment was related to the self-evaluation scores after treatment (r = 0.54; P<0.001). As in other studies,8,31 greater clinical improvement was associated with self-evaluations of improved memory.
Long-Term Cognitive Side Effects
Sixty-six patients were evaluated at the two-month follow-up, of whom 54 (82 percent) had responded to electroconvulsive therapy during either the randomized or the crossover phase. There were no effects related to treatment conditions in which electroconvulsive therapy was administered (data not shown). For these 66 patients, scores improved significantly from the pretreatment values on the Mini-Mental State Examination (P<0.001) and for paired-word learning (P = 0.02), paired-face learning (P = 0.03), and learning on the Selective Reminding Test (P = 0.03). Forgetting scores on these anterograde tests were unchanged relative to the pretreatment scores. Scores on the retrograde Autobiographical Memory Interview indicated no change in the consistency of recall relative to the post-treatment value. Subjective evaluations of memory were markedly improved at follow-up, in relation to the pretreatment scores (P<0.001), and were improved further in relation to those after treatment (P = 0.04).
Discussion
This study demonstrates that electrical dose affects the efficacy of electroconvulsive therapy. Despite the advantage of diminished cognitive side effects,7 the extremely poor efficacy of low-dose right unilateral therapy indicates that it should be abandoned. At all times examined, the high-dose right unilateral group had an antidepressant response superior to that of the low-dose right unilateral group. Dosage effects may account for the inconsistent results of previous research comparing right unilateral and bilateral electroconvulsive therapy10-16. Dosage also influenced the speed of clinical response with both right unilateral and bilateral therapy. Both high-dose groups had more rapid improvement than the low-dose groups. This is of particular importance, since electroconvulsive therapy is frequently used when rapid improvement is needed.
One week after electroconvulsive therapy, there were indications that high-dose right unilateral therapy was less efficacious than either of the bilateral-therapy approaches. The choice for the high-intensity conditions of a dosage 2.5 times the initial seizure threshold was arbitrary. The efficacy of right unilateral electroconvulsive therapy might be enhanced by a further increase in electrical dose, yet retain the advantages of unilateral therapy with respect to cognitive side effects, because electrode placement had more pronounced and persistent effects on cognition than did dosage. For virtually all objective cognitive measures during the week after treatment, bilateral therapy resulted in greater deficits than did right unilateral therapy, whereas adverse effects of the higher-stimulus dose were not evident. Few studies have demonstrated differences among types of electroconvulsive therapy in cognitive side effects two or more weeks after therapy8,14,19. Likewise, at the two-month follow-up in this study, cognitive function was similar in all four treatment groups. As compared with the pretreatment values, the follow-up results revealed enhanced performance on measures of global cognitive function and learning and in the subjective evaluation of memory, without change in the capacity to retain information. This pattern reflected improvement in the objective and subjective cognitive deficits associated with severe depression. There is substantial evidence that major depression is characterized by deficits in the acquisition of new information (learning), but not by disturbances in the retention of information (forgetting)19,28.
The effects of stimulus intensity on efficacy, speed of response, and short-term cognitive side effects were not associated with the absolute electrical dose administered, but with whether or not the dosage substantially exceeded the seizure threshold. These findings concur with basic research suggesting that the seizure threshold acts as a filter for many of the neurobiologic and behavioral effects of electrical stimulation32,33. Our findings indicate that a patient with an initial threshold of 60 millicoulombs (mC) who is treated with a 150-mC stimulus is likely to respond more quickly -- or to respond at all, if treated with right unilateral electroconvulsive therapy -- than a patient with a threshold of 300 mC who is treated with an electrical dose just above that threshold. Similarly, the first patient is likely to have more short-term cognitive side effects. This underscores the desirability of adjusting the stimulus intensity in relation to each patient's seizure threshold2. Case reports have raised the possibility that stimulation at subconvulsive levels that is used to identify the seizure threshold increases the risk of cardiovascular complications34-36. In a recent study of depressed patients with and without preexisting cardiac disease, however, cardiovascular complications were slightly more common after treatment sessions involving only stimulation at convulsive levels, as compared with those in which stimuli were also administered at subconvulsive levels37.
As in other recent follow-up studies of patients who responded to electroconvulsive therapy,38,39 the relapse rate was high despite conventional maintenance pharmacotherapy. Relapse is a critical problem. In other work, we found that failure to respond to antidepressant medications during the acute phase of illness was a potent predictor of relapse after therapy26. It is common for patients to receive the same class of antidepressant medication after electroconvulsive therapy that proved ineffective during treatment of the acute episode, but this practice should be reconsidered.
Low-dose right unilateral electroconvulsive therapy resulted in generalized seizures of adequate duration, but with little benefit. This contradicts the view that the duration of seizures provides a valid index of maximally effective treatment1,3,4 and indicates the need to identify more useful markers. It also contradicts the longstanding principle that the generalized seizure provides both the necessary and the sufficient conditions for the efficacy of electroconvulsive therapy. It now appears that the generalized seizure may be necessary, but not sufficient, to ensure a clinical response. The finding that there are electrical dose-response functions for electroconvulsive therapy offers new avenues to investigate the mechanisms of action of this treatment.
Supported in part by grants (R37 MH35636 and R01 MH47739) from the National Institute of Mental Health.
We are indebted to Dr. R.P. Brown, Dr. P. Decina, Dr. D. Kahn, Ms. B. Kerr, Dr. D. Malaspina, Dr. S. Malitz, Dr. L. Rosnick, Ms. F. Ross, Ms. J. Silverman, and the staff of the General Clinical Research Service, without whose help this study could not have been carried out.
Source Information
From the Department of Biological Psychiatry, New York State Psychiatric Institute, and the Department of Psychiatry, College of Physicians and Surgeons, Columbia University -- both in New York.
Address reprint requests to Dr. Sackeim at the Department of Biological Psychiatry, New York State Psychiatric Institute, 722 W. 168th St., New York, NY 10032.
- References
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- Citing Articles (291)
Citing Articles
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Verònica Gálvez, Angelo Alonzo, Donel Martin, Colleen K. Loo. (2012) Transcranial direct current stimulation treatment protocols: should stimulus intensity be constant or incremental over multiple sessions?. The International Journal of Neuropsychopharmacology1-9
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Sinead O'Donovan, Mark Kennedy, Blaithin Guinan, Shane O'Mara, Declan M. McLoughlin. (2011) A comparison of brief pulse and ultrabrief pulse electroconvulsive stimulation on rodent brain and behaviour. Progress in Neuro-Psychopharmacology and Biological Psychiatry
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Ross A. Dunne, Declan M. McLoughlin. (2011) Systematic review and meta-analysis of bifrontal electroconvulsive therapy versus bilateral and unilateral electroconvulsive therapy in depression. World Journal of Biological Psychiatry1-11
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Viktoria Stelzhammer, Matthias Rothermundt, Paul C. Guest, Nikolaus Michael, Carina Sondermann, Wolfgang Kluge, Daniel Martins-de-Souza, Hassan Rahmoune, Sabine Bahn. (2011) Proteomic changes induced by anaesthesia and muscle relaxant treatment prior to electroconvulsive therapy. PROTEOMICS - Clinical Applicationsn/a-n/a
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Kyle A.B. Lapidus, Charles H. Kellner. (2011) When to Switch From Unilateral to Bilateral Electroconvulsive Therapy. The Journal of ECT 27:3, 244-246
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Siwei Bai, Colleen Loo, Amr Al Abed, Socrates Dokos. (2011) A computational model of direct brain excitation induced by electroconvulsive therapy: comparison among three conventional electrode placements. Brain Stimulation
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Martijn Meeter, Jaap M.J. Murre, Steve M.J. Janssen, Tom Birkenhager, W.W. van den Broek. (2011) Retrograde amnesia after electroconvulsive therapy: A temporary effect?. Journal of Affective Disorders 132:1-2, 216-222
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Maria Semkovska, Deborah Keane, Oyemi Babalola, Declan M. McLoughlin. (2011) Unilateral brief-pulse electroconvulsive therapy and cognition: Effects of electrode placement, stimulus dosage and time. Journal of Psychiatric Research 45:6, 770-780
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Sarah Kayser, Bettina H. Bewernick, Christiane Grubert, Barbara L. Hadrysiewicz, Nikolai Axmacher, Thomas E. Schlaepfer. (2011) Antidepressant effects, of magnetic seizure therapy and electroconvulsive therapy, in treatment-resistant depression. Journal of Psychiatric Research 45:5, 569-576
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Iannis M. Zervas, Christos Theleritis, Costantin R. Soldatos. (2011) Using ECT in schizophrenia: A review from a clinical perspective. World Journal of Biological Psychiatry1-10
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Eva-Lotta Brakemeier, Robert Berman, Joan Prudic, Karen Zwillenberg, Harold A. Sackeim. (2011) Self-Evaluation of the Cognitive Effects of Electroconvulsive Therapy. The Journal of ECT 27:1, 59-66
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Keith G. Rasmussen. (2011) Some Considerations in Choosing Electroconvulsive Therapy Versus Transcranial Magnetic Stimulation for Depression. The Journal of ECT 27:1, 51-54
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G. Perugi, P. Medda, S. Zanello, C. Toni, G.B. Cassano. (2011) Episode length and mixed features as predictors of ECT nonresponse in patients with medication-resistant major depression. Brain Stimulation
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Hazem Shoirah, Hesham M Hamoda. (2011) Electroconvulsive therapy in children and adolescents. Expert Review of Neurotherapeutics 11:1, 127-137
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Anne M Landau, M Mallar Chakravarty, Campbell M Clark, Athanasios P Zis, Doris J Doudet. (2011) Electroconvulsive Therapy Alters Dopamine Signaling in the Striatum of Non-human Primates. Neuropsychopharmacology 36:2, 511-518
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Chris PLAKIOTIS, Loi Fei CHIN, Daniel W. O'CONNOR, . (2010) The change in electrical energy delivered to aged patients over a course of moderate dose unilateral electroconvulsive therapy. Psychogeriatrics 10:4, 187-190
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Mark S George. (2010) Transcranial magnetic stimulation for the treatment of depression. Expert Review of Neurotherapeutics 10:11, 1761-1772
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Mark S. George. 2010. Somatic Treatments for Bipolar Disorder: ECT, VNS and TMS. , 384-394.
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Angel V. Peterchev, Moacyr A. Rosa, Zhi-De Deng, Joan Prudic, Sarah H. Lisanby. (2010) Electroconvulsive Therapy Stimulus Parameters. The Journal of ECT 26:3, 159-174
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Colleen Loo, Brett Simpson, Ross MacPherson. (2010) Augmentation Strategies in Electroconvulsive Therapy. The Journal of ECT 26:3, 202-207
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Maria Semkovska, Declan M. McLoughlin. (2010) Objective Cognitive Performance Associated with Electroconvulsive Therapy for Depression: A Systematic Review and Meta-Analysis. Biological Psychiatry 68:6, 568-577
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Charles H. Kellner, Kristen G. Tobias, Jessica Wiegand. (2010) Electrode Placement in Electroconvulsive Therapy (ECT). The Journal of ECT 26:3, 175-180
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Kenneth Trevino, Shawn M. McClintock, Mustafa M. Husain. (2010) A Review of Continuation Electroconvulsive Therapy. The Journal of ECT 26:3, 186-195
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Bangalore N. Gangadhar, Jagadisha Thirthalli. (2010) Frequency of Electroconvulsive Therapy Sessions in a Course. The Journal of ECT 26:3, 181-185
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Roger F. Haskett, Colleen Loo. (2010) Adjunctive Psychotropic Medications During Electroconvulsive Therapy in the Treatment of Depression, Mania, and Schizophrenia. The Journal of ECT 26:3, 196-201
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Colleen K. Loo, Andrew Kaill, Pauline Paton, Brett Simpson. (2010) The difficult-to-treat electroconvulsive therapy patient — Strategies for augmenting outcomes. Journal of Affective Disorders 124:3, 219-227
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D. W. Falconer, J. Cleland, S. Fielding, I. C. Reid. (2010) Using the Cambridge Neuropsychological Test Automated Battery (CANTAB) to assess the cognitive impact of electroconvulsive therapy on visual and visuospatial memory. Psychological Medicine 40:06, 1017-1025
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Ayşegül Yildiz, Atil Mantar, Selçuk Simsek, Elif Onur, Necati Gökmen, Hüray Fidaner. (2010) Combination of Pharmacotherapy With Electroconvulsive Therapy in Prevention of Depressive Relapse. The Journal of ECT 26:2, 104-110
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Johanna Palmio, Martti Huuhka, Seppo Laine, Heini Huhtala, Jukka Peltola, Esa Leinonen, Jaana Suhonen, Tapani Keränen. (2010) Electroconvulsive therapy and biomarkers of neuronal injury and plasticity: Serum levels of neuron-specific enolase and S-100b protein. Psychiatry Research 177:1-2, 97-100
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P. Sienaert, K. Vansteelandt, K. Demyttenaere, J. Peuskens. (2010) Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: cognitive side-effects. Journal of Affective Disorders 122:1-2, 60-67
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C. H. Kellner, R. Knapp, M. M. Husain, K. Rasmussen, S. Sampson, M. Cullum, S. M. McClintock, K. G. Tobias, C. Martino, M. Mueller, S. H. Bailine, M. Fink, G. Petrides. (2010) Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial. The British Journal of Psychiatry 196:3, 226-234
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Richard C. Shelton, Olawale Osuntokun, Alexandra N. Heinloth, Sara A. Corya. (2010) Therapeutic Options for Treatment-Resistant Depression. CNS Drugs 24:2, 131-161
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Keith G. Rasmussen, Susanna R. Stevens, Simon Kung, Amit Mohan. (2010) Melancholic symptoms as assessed by the Hamilton Depression Rating Scale and outcomes with and without electroconvulsive therapy on an in-patient mood disorders unit. Acta Neuropsychiatrica 22:1, 21-25
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Georgios Petrides, Raphael J. Braga, Max Fink, Martina Mueller, Rebecca Knapp, Mustafa Husain, Teresa Rummans, Samuel Bailine, Chitra Malur, Kevin O'Connor, Charles Kellner. (2009) Seizure Threshold in a Large Sample. The Journal of ECT 25:4, 232-237
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Jeroen A. Waarde, Bastiaan Verwey, Rose C. Mast. (2009) Meta-analysis of initial seizure thresholds in electroconvulsive therapy. European Archives of Psychiatry and Clinical Neuroscience 259:8, 467-474
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Sidney H. Kennedy, Roumen Milev, Peter Giacobbe, Rajamannar Ramasubbu, Raymond W. Lam, Sagar V. Parikh, Scott B. Patten, Arun V. Ravindran. (2009) Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults.. Journal of Affective Disorders 117, S44-S53
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Angela Merkl, Isabella Heuser, Malek Bajbouj. (2009) Antidepressant electroconvulsive therapy: Mechanism of action, recent advances and limitations. Experimental Neurology 219:1, 20-26
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Nancy A. Payne, Joan Prudic. (2009) Electroconvulsive Therapy: Part I. A Perspective on the Evolution and Current Practice of ECT. Journal of Psychiatric Practice 15:5, 346-368
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Charles H. Kellner, Max Fink. (2009) Electroconvulsive therapy in the treatment of intractable status epilepticus. Epilepsy & Behavior 16:1, 189-190
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Yael M. Cycowicz, Bruce Luber, Timothy Spellman, Sarah H. Lisanby. (2009) Neurophysiological Characterization of High-Dose Magnetic Seizure Therapy. The Journal of ECT 25:3, 157-164
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Linda L. Carpenter, Noah S. Philip, John O'Reardon. 2009. Advances in Neurostimulation for Depression: Electroconvulsive Therapy, Transcranial Magnetic Stimulation, Vagus Nerve Stimulation, and Deep Brain Stimulation. , 166-185.
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Timothy Spellman, Angel V Peterchev, Sarah H Lisanby. (2009) Focal Electrically Administered Seizure Therapy: A Novel form of ECT Illustrates the Roles of Current Directionality, Polarity, and Electrode Configuration in Seizure Induction. Neuropsychopharmacology 34:8, 2002-2010
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P. Sienaert, K. Vansteelandt, K. Demyttenaere, J. Peuskens. (2009) Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: Clinical efficacy. Journal of Affective Disorders 116:1-2, 106-112
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Jeroen A. van Waarde, Michael E.M.T. Muller, Bastiaan Verwey, Rose C. van der Mast. (2009) Exceptionally High Initial Seizure Threshold in a Catatonic Patient Treated With Electroconvulsive Therapy. The Journal of ECT 25:2, 121-124
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Jeanett Bauer, Ida Hageman, Henrik Dam, Armando Báez, Tom Bolwig, Jakob Roed, Niels Vidiendal Olsen, Martin Balslev Jørgensen. (2009) Comparison of Propofol and Thiopental as Anesthetic Agents for Electroconvulsive Therapy. The Journal of ECT 25:2, 85-90
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Sarah Kayser, Bettina Bewernick, Nikolai Axmacher, Thomas E. Schlaepfer. (2009) Magnetic Seizure Therapy of Treatment-Resistant Depression in a Patient With Bipolar Disorder. The Journal of ECT 25:2, 137-140
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Keith G. Rasmussen. (2009) Sham Electroconvulsive Therapy Studies in Depressive Illness. The Journal of ECT 25:1, 54-59
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Titus SP Mohan, Prathap Tharyan, Jacob Alexander, Nirmal S Raveendran. (2009) Effects of stimulus intensity on the efficacy and safety of twice-weekly, bilateral electroconvulsive therapy (ECT) combined with antipsychotics in acute mania: a randomised controlled trial. Bipolar Disorders 11:2, 126-134
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Savithasri V. Eranti, Andrew J. Mogg, Graham C. Pluck, Sabine Landau, Declan M. McLoughlin. (2009) Methohexitone, propofol and etomidate in electroconvulsive therapy for depression: A naturalistic comparison study. Journal of Affective Disorders 113:1-2, 165-171
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Mark S. George, Frank Padberg, Thomas E. Schlaepfer, John P. O'Reardon, Paul B. Fitzgerald, Ziad H. Nahas, Marco A. Marcolin. (2009) Controversy: Repetitive transcranial magnetic stimulation or transcranial direct current stimulation shows efficacy in treating psychiatric diseases (depression, mania, schizophrenia, obsessive-complusive disorder, panic, posttraumatic stress disorder). Brain Stimulation 2:1, 14-21
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K.T. Hallam, D.I. Smith, M. Berk. (2009) Differences between subjective and objective assessments of the utility of Electroconvulsive therapy in patients with bipolar and unipolar depression. Journal of Affective Disorders 112:1-3, 212-218
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James N. Kimball, Peter B. Rosenquist, Aaron Dunn, Vaughn McCall. (2009) Prediction of antidepressant response in both 2.25×threshold RUL and fixed high dose RUL ECT. Journal of Affective Disorders 112:1-3, 85-91
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Sarah H. Lisanby, Shirlene Sampson, Mustafa M. Husain, Georgios Petrides, Rebecca G. Knapp, Vaughn McCall, Robert C. Young, Joan Prudic, Charles H. Kellner. (2008) Toward Individualized Post-Electroconvulsive Therapy Care. The Journal of ECT 24:3, 179-182
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Majid Barekatain, Leila Jahangard, Mohammad Haghighi, Farzad Ranjkesh. (2008) Bifrontal Versus Bitemporal Electroconvulsive Therapy in Severe Manic Patients. The Journal of ECT 24:3, 199-202
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Martin Knapp, Renee Romeo, Andrew Mogg, Savitha Eranti, Graham Pluck, Rick Purvis, Richard G. Brown, Robert Howard, Michael Philpot, John Rothwell, Denzil Edwards, Declan M. McLoughlin. (2008) Cost-effectiveness of transcranial magnetic stimulation vs. electroconvulsive therapy for severe depression: A multi-centre randomised controlled trial. Journal of Affective Disorders 109:3, 273-285
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Victor Navarro, Cristóbal Gastó, Xavier Torres, Guillem Masana, Rafael Penadés, Joana Guarch, Mireia Vázquez, Montserrat Serra, Nuria Pujol, Luis Pintor, Rosa Catalán. (2008) Continuation/Maintenance Treatment with Nortriptyline Versus Combined Nortriptyline and ECT in Late-Life Psychotic Depression: A Two-Year Randomized Study. American Journal of Geriatric Psychiatry 16:6, 498-505
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Timothy Spellman, Shawn M. McClintock, Herbert Terrace, Bruce Luber, Mustafa M. Husain, Sarah H. Lisanby. (2008) Differential Effects of High-Dose Magnetic Seizure Therapy and Electroconvulsive Shock on Cognitive Function. Biological Psychiatry 63:12, 1163-1170
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Max Fink, Georgios Petrides, Charles Kellner, Martina Mueller, Rebecca Knapp, Mustafa M. Husain, Keith Rasmussen, Teri Rummans, Kevin O'Connor. (2008) Change in Seizure Threshold During Electroconvulsive Therapy. The Journal of ECT 24:2, 114-116
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Mark D. Williams, Teresa Rummans, Shirlene Sampson, Rebecca Knapp, Martina Mueller, Mustafa M. Husain, Max Fink, Keith Rasmussen, Kevin O'Connor, Glenn Smith, George Petrides, Charles H. Kellner. (2008) Outcome of Electroconvulsive Therapy by Race in the Consortium for Research on Electroconvulsive Therapy Multisite Study. The Journal of ECT 24:2, 117-121
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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. (2008) Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. Brain Stimulation 1:2, 71-83
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Bernard Lerer, Moshe Isserles. (2008) From Meduna to ultrabrief: New directions for the oldest brain stimulation therapy. Brain Stimulation 1:2, 84-85
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Marina Vamos. (2008) The Cognitive Side Effects of Modern ECT. The Journal of ECT 24:1, 18-24
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Richard John Porter, Katie Douglas, Robert G. Knight. (2008) Monitoring of Cognitive Effects During a Course of Electroconvulsive Therapy. The Journal of ECT 24:1, 25-34
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Richard Porter, Helen Heenan, Jo Reeves. (2008) Early Effects of Electroconvulsive Therapy on Cognitive Function. The Journal of ECT 24:1, 35-39
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Joan Prudic. (2008) Strategies to Minimize Cognitive Side Effects With ECT. The Journal of ECT 24:1, 46-51
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Anna Ingram, Michael M. Saling, Isaac Schweitzer. (2008) Cognitive Side Effects of Brief Pulse Electroconvulsive Therapy. The Journal of ECT 24:1, 3-9
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Louisa M. Fraser, Ronan E. O'Carroll, Klaus P. Ebmeier. (2008) The Effect of Electroconvulsive Therapy on Autobiographical Memory. The Journal of ECT 24:1, 10-17
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Mitchell S. Nobler, Harold A. Sackeim. (2008) Neurobiological Correlates of the Cognitive Side Effects of Electroconvulsive Therapy. The Journal of ECT 24:1, 40-45
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Robert M. Berman, Joan Prudic, Eva-Lotta Brakemeier, Mark Olfson, Harold A. Sackeim. (2008) Subjective evaluation of the therapeutic and cognitive effects of electroconvulsive therapy. Brain Stimulation 1:1, 16-26
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Harold A. Sackeim, Mark S. George. (2008) Brain stimulation—basic, translational, and clinical research in neuromodulation: Why a new journal?. Brain Stimulation 1:1, 4-6
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Keith G. Rasmussen, Rebecca G. Knapp, Melanie M. Biggs, Glenn E. Smith, Teresa A. Rummans, Georgios Petrides, Mustafa M. Husain, M. Kevin O'Connor, Max Fink, Charles H. Kellner. (2007) Data Management and Design Issues in an Unmasked Randomized Trial of Electroconvulsive Therapy for Relapse Prevention of Severe Depression. The Journal of ECT 23:4, 244-250
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Harold A. Sackeim, Stephen K. Brannan, A. John Rush, Mark S. George, Lauren B. Marangell, John Allen. (2007) Durability of antidepressant response to vagus nerve stimulation (VNS). The International Journal of Neuropsychopharmacology 10:06,
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Lisanby, Sarah H., . (2007) Electroconvulsive Therapy for Depression. New England Journal of Medicine 357:19, 1939-1945
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Colleen Loo, Patrick Sheehan, Melissa Pigot, William Lyndon. (2007) A report on mood and cognitive outcomes with right unilateral ultrabrief pulsewidth (0.3 ms) ECT and retrospective comparison with standard pulsewidth right unilateral ECT. Journal of Affective Disorders 103:1-3, 277-281
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Melina Siamouli, Stamatia Magiria, Panagiotis Panagiotidis, Styliani Spyridi, Stavroula Sokolaki, Konstantinos N Fountoulakis, George Kaprinis. (2007) Advances in the treatment of geriatric depression. Aging Health 3:4, 495-507
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Gerhard W. Eschweiler, Reinhard Vonthein, Ruediger Bode, Michael Huell, Andreas Conca, Oliver Peters, Stefan Mende-Lechler, Julia Peters, Dorothee Klecha, Michael Prapotnik, Jan DiPauli, Barbara Wild, Christian Plewnia, Mathias Bartels, Wilfried Schlotter. (2007) Clinical efficacy and cognitive side effects of bifrontal versus right unilateral electroconvulsive therapy (ECT): A short-term randomised controlled trial in pharmaco-resistant major depression. Journal of Affective Disorders 101:1-3, 149-157
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Harold A. Sackeim, Joan Prudic, Mark Olfson. (2007) Response to Drs Abrams and Kellner. The Journal of ECT 23:2, 65-67
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Joseph J. Rasimas, Susanna R. Stevens, Keith G. Rasmussen. (2007) Seizure Length in Electroconvulsive Therapy as a Function of Age, Sex, and Treatment Number. The Journal of ECT 23:1, 14-16
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Friedel M. Reischies, Alexander Gabriel, Nadine Zerhoch, Andres H. Neuhaus. (2007) Untersuchungen zu psychopathologischen und neuropsychologischen Symptomen des Delirs. Zeitschrift für Gerontopsychologie & -psychiatrie 20:2, 141-149
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Harold A Sackeim, Joan Prudic, Rice Fuller, John Keilp, Philip W Lavori, Mark Olfson. (2007) The Cognitive Effects of Electroconvulsive Therapy in Community Settings. Neuropsychopharmacology 32:1, 244-254
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Mark S George, Ziad Nahas, Jeffrey J Borckardt, Berry Anderson, Carol Burns, Samet Kose, E Baron Short. (2007) Vagus nerve stimulation for the treatment of depression and other neuropsychiatric disorders. Expert Review of Neurotherapeutics 7:1, 63-74
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Moacyr Alexandro Rosa, Marina O. Rosa, Claudiane S. Daltio, Lena N. Abreu, Marco A. Marcolin. (2006) Open Trial on the Efficacy of Right Unilateral Electroconvulsive Therapy With Titration and High Charge. The Journal of ECT 22:4, 237-239
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Keith G. Rasmussen, Daniel R. Laurila, Bret M. Brady, Christy L. Lewis, Kimberly D. Niemeyer, Norazlina M. Sun, Marie E. S. Marienau, W. Michael Hooten, Darrell R. Schroeder, Thomas M. Spackman. (2006) Seizure Length With Sevoflurane and Thiopental for Induction of General Anesthesia in Electroconvulsive Therapy. The Journal of ECT 22:4, 240-242
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Prashanth Mayur. (2006) Ictal Electroencephalographic Characteristics During Electroconvulsive Therapy. The Journal of ECT 22:3, 213-217
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Jyoti Prakash, Atul Kotwal, HRA Prabhu. (2006) Therapeutic and Prophylactic Utility of the Memory-Enhancing Drug Donepezil Hydrochloride on Cognition of Patients Undergoing Electroconvulsive Therapy. The Journal of ECT 22:3, 163-168
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A John Rush, Helena C Kraemer, Harold A Sackeim, Maurizio Fava, Madhukar H Trivedi, Ellen Frank, Philip T Ninan, Michael E Thase, Alan J Gelenberg, David J Kupfer, Darrel A Regier, Jerrold F Rosenbaum, Oakley Ray, Alan F Schatzberg. (2006) Report by the ACNP Task Force on Response and Remission in Major Depressive Disorder. Neuropsychopharmacology 31:9, 1841-1853
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WARREN K. WARD, PAMELA LUSH, MARILYN KELLY, AARON D. J. FROST. (2006) A naturalistic comparison of two right unilateral electroconvulsive therapy dosing protocols: 2-3X seizure threshold versus fixed high-dose. Psychiatry and Clinical Neurosciences 60:4, 429-433
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Akiko Fujita, Shutaro Nakaaki, Kazuhisa Segawa, Hideki Azuma, Kiyoe Sato, Keiko Arahata, Kazuyuki Otsuki, Miki Hori, Yoshihito Mochida, Megumi Uchida, Tomoko Yamada, Chie Nakamura, Tatsuo Akechi, Toshi A. Furukawa. (2006) Memory, Attention, and Executive Functions Before and After Sine and Pulse Wave Electroconvulsive Therapies for Treatment-Resistant Major Depression. The Journal of ECT 22:2, 107-112
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Keith G. Rasmussen, Martina Mueller, Charles H. Kellner, Rebecca G. Knapp, George Petrides, Teresa A. Rummans, Mustafa M. Husain, M. Kevin O'Connor, John L. Black, Shirlene Sampson, Max Fink. (2006) Patterns of Psychotropic Medication Use Among Patients with Severe Depression Referred for Electroconvulsive Therapy. The Journal of ECT 22:2, 116-123
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Thomas E. Schlaepfer, Markus Kosel, Hans-Ulrich Fisch. (2006) Repetitive transcranial magnetic stimulation (rTMS) in depression. Poiesis & Praxis 4:2, 111-127
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Alberto Stoppe, Mario Louz??, Moacyr Rosa, Gislaine Gil, S??rgio Rigonatti. (2006) Fixed High-Dose Electroconvulsive Therapy in the Elderly With Depression. The Journal of ECT 22:2, 92-99
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Milton J. Foust, Mark S. George. 2006. Electroconvulsive Therapy. .
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Michael Prapotnik, Roger Pycha, Csaba Nemes, Peter König, Armand Hausmann, Andreas Conca. (2006) Kognitive Störungen und Elektrokrampftherapie. Wiener Medizinische Wochenschrift 156:5-6, 200-208
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Conrad M. Swartz. (2006) Electroconvulsive Therapy Stimulus Dose Expressed as Volume of Seizure Foci. The Journal of ECT 22:1, 54-58
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Worrawat Chanpattana, Chittaranjan Andrade. (2006) ECT for Treatment-Resistant Schizophrenia. The Journal of ECT 22:1, 4-12
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Colleen K. Loo, Isaac Schweitzer, Chris Pratt. (2006) Recent advances in optimizing electroconvulsive therapy. Australian and New Zealand Journal of Psychiatry 40:8, 632-638
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Paul J. Carlson, Jaskaran B. Singh, Carlos A. Zarate, Wayne C. Drevets, Husseini K. Manji. (2006) Neural circuitry and neuroplasticity in mood disorders: Insights for novel therapeutic targets. NeuroRX 3:1, 22-41
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John W.G. Tiller, Nicholas Ingram. (2006) Seizure threshold determination for electroconvulsive therapy: stimulus dose titration versus age-based estimations. Australian and New Zealand Journal of Psychiatry 40:2, 188-192
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Farzad Ranjkesh, Majid Barekatain, Shahla Akuchakian. (2005) Bifrontal Versus Right Unilateral and Bitemporal Electroconvulsive Therapy in Major Depressive Disorder. The Journal of ECT 21:4, 207-210
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Johanna Palmio, Martti Huuhka, Pirjo Saransaari, Simo S. Oja, Jukka Peltola, Esa Leinonen, Jaana Suhonen, Tapani Keränen. (2005) Changes in plasma amino acids after electroconvulsive therapy of depressed patients. Psychiatry Research 137:3, 183-190
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Harold A Sackeim, Joan Prudic. (2005) Length of the ECT Course in Bipolar and Unipolar Depression. The Journal of ECT 21:3, 195-197
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Mark S. George, A. John Rush, Lauren B. Marangell, Harold A. Sackeim, Stephen K. Brannan, Sonia M. Davis, Robert Howland, Mitchel A. Kling, Francisco Moreno, Barry Rittberg, David Dunner, Thomas Schwartz, Linda Carpenter, Michael Burke, Philip Ninan, Paul Goodnick. (2005) A One-Year Comparison of Vagus Nerve Stimulation with Treatment as Usual for Treatment-Resistant Depression. Biological Psychiatry 58:5, 364-373
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Thomas C Baghai, Flavia di Michele, Cornelius Schüle, Daniela Eser, Peter Zwanzger, Augusto Pasini, Elena Romeo, Rainer Rupprecht. (2005) Plasma Concentrations of Neuroactive Steroids before and after Electroconvulsive Therapy in Major Depression. Neuropsychopharmacology 30:6, 1181-1186
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Humberto Quintana. (2005) Transcranial Magnetic Stimulation in Persons Younger Than the Age of 18. The Journal of ECT 21:2, 88-95
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T. C. Baghai, A. Marcuse, H.-J. Möller, R. Rupprecht. (2005) Elektrokonvulsionstherapie an der Klinik für Psychiatrie und Psychotherapie der Universität München. Der Nervenarzt 76:5, 597-612
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Elissa M. Strome, Campbell M. Clark, Athanasios P. Zis, Doris J. Doudet. (2005) Electroconvulsive shock decreases binding to 5-HT2 receptors in nonhuman primates: An in vivo positron emission tomography study with [18F]setoperone. Biological Psychiatry 57:9, 1004-1010
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Prathap Tharyan, Clive E Adams, Prathap Tharyan. 2005. Electroconvulsive therapy for schizophrenia. .
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Robert M. Greenberg, Charles H. Kellner. (2005) Electroconvulsive Therapy. American Journal of Geriatric Psychiatry 13:4, 268-281
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Pascal Sienaert, Bouckaert Filip, Milo Willy, Peuskens Joseph. (2005) Electroconvulsive Therapy in Belgium. The Journal of ECT 21:1, 3-6
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Rachel E Dew, James N Kimball, Peter B Rosenquist, W Vaughn McCall. (2005) Seizure Length and Clinical Outcome in Electroconvulsive Therapy Using Methohexital or Thiopental. The Journal of ECT 21:1, 16-18
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M. Bajbouj, I. Heuser. (2005) Antidepressive Stimulationsverfahren. Der Nervenarzt 76:1, 28-35
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John D. Little, Jo Munday, Martin R. Atkins, Abdul Khalid. (2004) Does Electrode Placement Predict Time to Rehospitalization?. The Journal of ECT 20:4, 213-218
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