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BACKGROUND: Electroconvulsive therapy (ECT) is the most effective acute treatment for severe depression, but widely held concerns about memory problems may limit its use. AIMS: To find out whether repeated or maintenance courses of ECT cause cumulative cognitive deterioration. METHOD: Analysis of the results of 10 years of cognitive performance data collection from patients who have received ECT. The 199 patients had a total of 498 assessments, undertaken after a mean of 15.3 ECT sessions (range 0-186). A linear mixed-effect regression model was used, testing whether an increasing number of ECT sessions leads to deterioration in performance. RESULTS: The total number of previous ECT sessions had no effect on cognitive performance. The major factors affecting performance were age, followed by the severity of depression at the time of testing and the number of days since the last ECT session. CONCLUSIONS: Repeated courses of ECT do not lead to cumulative cognitive deficits. This message is reassuring for patients, carers and prescribers who are concerned about memory problems and confusion during ECT.

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BACKGROUND: Magnetic seizure therapy, in which seizures are elicited with a high-frequency magnetic field, is under development as a new treatment for major depressive disorder. Its use may be justified if it produces the antidepressant effects of electroconvulsive therapy (ECT), coupled with limited cognitive side-effects. AIMS: To evaluate the usefulness of a new 100 Hz magnetic seizure therapy device. METHOD: We induced seizures with 100 Hz magnetic transcranial stimulation in 11 patients with major depressive disorder during one session of a regular course of ECT. Recovery times after seizures induced by magnetic seizure therapy and ECT were compared. RESULTS: Seizures could be elicited in 10 of the 11 patients. Stimulation over the vertex produced tonic-clonic activity on 9 out of 11 occasions. Stimulation over the prefrontal midpoint elicited seizures on 3 out of 7 occasions. The mean duration of magnetically induced seizures was 31.3 s, ranging from 10 to 86 s. All patients had an exceptionally quick recovery of orientation: mean of 7 min 12 s (s.d.=2 min 7 s, range 4 min 20 s to 9 min 41 s). The recovery times were on average 15 min 35 s shorter with magnetic seizure therapy than with ECT in the same patients (paired-samples t-test: P<0.0001). Patients reported feeling less confused after magnetic seizure therapy. Side-effects were confined to myoclonic movements, associated with the use of etomidate. CONCLUSIONS: The new 100 Hz magnetic stimulator elicits seizures in the majority of patients when administered over the vertex. Magnetic seizure therapy was associated with shorter recovery times and less confusion following treatment. Subsequent work will be required to assess the safety and effectiveness of magnetic seizure therapy in the treatment of depression.

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OBJECTIVES: Electroconvulsive therapy (ECT) is a very effective treatment of major depressive disorder. However, its use has been declining over the years in the United Kingdom, where it is now reserved for cases where all other treatment options have failed. We wanted to assess whether ECT is still highly effective in such a severely treatment-resistant population. METHODS: We report results from an ongoing, prospectively conducted, naturalistic study examining the effectiveness of ECT at a general psychiatric hospital in Cardiff, United Kingdom. We present results on every patient who received ECT between March 2004 and August 2006 for major depressive episodes, had a baseline 24-item Hamilton Rating Scale for Depression (HRSD24) score of greater than or equal to 18 and consented for participation. RESULTS: We analyzed the results of 38 patients who had at least 6 ECT sessions or achieved remission earlier. They had spent on average 14.6 months in their current episodes and 6.2 years of their lifetime in depression. They had failed to respond to an average of 5.4 different pharmacological treatments. Twenty-five patients (65.8%) responded (improvement in HDRS24 of >or=50%) and 21 (53.3%) achieved remission (end point HDRS24 score or=60%). There was no correlation between the number of unsuccessful antidepressant trials and improvement (r = -0.04, P = 0.8). CONCLUSIONS: The ECT is still highly effective in severely treatment-resistant patients with major depressive disorder, with more than half of such patients achieving remission.

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OBJECTIVE: Methohexital used to be the preferred anesthetic used in electroconvulsive therapy (ECT). Since 1999, there have been supply problems for this drug, and there has been no clear guidance regarding which anesthetic should be used preferably in ECT. Most clinics use thiopental or propofol, although these drugs may increase the seizure threshold. We investigated if etomidate improves seizure duration compared with thiopental in cases where eliciting seizures becomes problematic. METHODS: During our routine delivery of ECT at a general psychiatric hospital in Cardiff, UK, we observed 5 patients who had ECT courses with thiopental and did not achieve adequate seizure duration despite very high electric stimulation. They later relapsed and received second courses of ECT under etomidate. We compared the seizure duration and the electric charge needed to produce the seizures for a total of 46 pairs of ECT sessions given under the 2 anesthetics on the same patients. RESULTS: The average electric stimulation dose required to induce seizures was reduced from 638 to 497 millicoulombs (95% confidence interval, 60-221; P = 0.001). Despite the lower dose, the length of observed seizure duration increased by 10.3 seconds (65%) and that of the electroencephalograph-recorded duration increased by 8.7 seconds (41%) (P < 0.001). CONCLUSIONS: Etomidate has a distinct advantage over thiopental in producing seizures of adequate duration during ECT and should be used as the first-line measure in augmenting seizures in patients who have very high seizure thresholds.

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