poster Satish Jothi

A Retrospective study of the Outcomes in Right Unilateral Ultra-Brief
Pulse width ECT (RUL-UB) for the treatment of depression in older
adults.
AUTHORED BY: Dr Jothi Ramalingam and Dr Sathish Thangapandian, Specialist Mental Health Services for Older People, Central Coast Local health District, NSW, Australia
Introduction
Depression is a common illness in the elderly. Electroconvulsive
therapy may be the treatment of choice for severe depressive
illness when there is an urgent need for treatment and as a
second- or third-line treatment of a depressive illness that has not
adequately responded to antidepressant treatment(1,2). Cognitive
impairment is a common side effect of ECT and RUL-UB
ECT(0.3ms) has been shown to cause less cognitive side effects
without compromising efficacy compared to brief pulse(0.5-1.5ms)
width ECT(3,4,5). However further studies have suggested that
treatment with RUL-UB ECT may require patients to have more
treatments due to slower response and switch to brief pulse width
due to ineffectiveness(4,5,6). Currently there is a dearth of data in
elderly patients who undergo RUL- UB ECT for depression. In our
centre, we have been offering RUL-UB ECT to older adults since
2009 and we are presenting the following data from this group.
Treatment outcome
Demographics
and Variables
RUL-UB
completers
Age
77 (66-89)
75 (65-85)
Gender:m
1 (5.9%)
15 (60%)
Diagnosis
Unipolar
Bipolar
12 (70.6%)
5 (29.4%)
Psychotic
Switchers
X2
t test
Total
.758
76 (65-89)
13.273
.001*
16 (38.1)
22 (88%)
3 (12%)
1.99
.158
34
8
6 (35.3%)
6 (24%)
0.632
.426
12
Catatonic
3 (17.6%)
2 (8%)
0.898
.343
5
Involuntary
6 (35.3%)
8 (32%)
0.049
.824
14
Prev ECT
9 (52.9%)
12 (48%)
0.099
.753
21
Duration of
current episode
in weeks
35.25 (5-156)
23.7 (4-104)
0.996
.329
28.83 (4-156)
Current Episode
>2 yrs
1 (5.9%)
0
2.965
.227
1
First Episode
1 (5.9%)
7 (28%)
3.21
.073
8
Past Episodes
2.5 (0-5)
2.64 (0-20)
2 or more trials
10 (58.8%)
15 (60%)
On antipsychotic
9 (52.9%)
17 (68%)
8.76
15.68
5.88**
9.8***
Total number of
ECT sessions
1.1.04
Significance
.9
2.6 (0-20)
.006
.939
25
0.973
.324
26
<.0001*
12.88 (3-26)
-.127
-4.881
** mean number of sessions before switch
*** mean number of sessions after switch
Proportion of patients switching to other types of ECT
Reasons for switch
Reasons for changing pulse width or electrode placement
We conducted a retrospective case note review of all the patients
over 65 starting an acute course of RUL-UB ECT after September
2009 with a diagnosis of a major depressive episode. We excluded
patients with significant neurological disorders, dementia,
personality disorders, rapid cycling bipolar and drug and alcohol
problems in the last 6 months and patients who have had ECT in
the last 3 months. The main outcome measure was clinical
impression as documented in the patient's notes just before
stopping the acute course of ECT and was classified as remission,
response and no improvement. We have an ECT treatment sheet
and a register which enabled us to identify total number of
treatments in the acute course and switch to other types of ECT.
When a patient had switched we identified the reasons for the
switch from the clinical notes. We also looked at other factors
including potential confounders like the presence of psychotic
symptoms, duration of current episode and history of previous
response to ECT.
ECT was administered using a Thymatron® system IV device 2 or
3 times a week. During the first treatment seizure threshold was
determined by titration and ECT was delivered at 6 times the
threshold. The dose was further increased depending on clinical
response and EEG morphology. Patients were switched to RUL or
Bilateral Brief pulse width treatments at any stage by the treating
clinician if the patients’ condition worsened or needed an urgent
improvement or failed to improve or only partially improve. RUL-UB
ECT had to be abandoned if the patient was found to have a high
seizure threshold on titration or if the dose increases during the
course of ECT resulted in doses over 504mc which is the
maximum dose that can be administered with ultra-brief
pulsewidth. took Succinylcholine was the muscle relaxant used;
Thiopentone (3-5mg/kg) was the usual anaesthetic and
occasionally Propofol was used based on clinical need.
Ineﬀective or only partially eﬀective
60% (15/25)
Dose increases and high seizure threshold not
.allowing ultra-brief pulse width treatment
24% (6/25)
Need for an urgent clinical improvement
12% (3/25)
Patient Preference
4% (1/25)
Illness or demographic variables between RUL-UB completers and
switchers were not significantly different apart from a higher
representation of males and first episode patients being over
represented in switchers.
Conclusion
This is the first report on outcomes of RUL-UB ECT for depression in
older adults. In our study, we found that RUL-UB ECT was effective in
a subgroup of older adults. Cognitive advantages of RUL-UB ECT is
established in younger adults. If similar findings are replicated in older
adults, RUL-UB ECT would be more acceptable in older adults who
are at higher risk of developing significant cognitive side effects. However, this might be offset by individuals requiring more number of
treatments and anaesthesia as we have seen in our subgroup of
switchers who required a higher number of treatments. Older adults
with multiple medical comorbidities are at a higher risk of anaesthetic
complications and anything that increases the number of treatments
would be to their disadvantage. Controlled studies of RUL-UB ECT in
older adults to study the efficacy, cognitive side effects and the speed
of response in relation to other electrode placements and pulsewidth
is required so we can better understand the role of different types of
ECT in Older adults with differing comorbidities.
Treatment Outcome
100%
90%
80%
70%
60%
50%
References
40%
30%
20%
10%
0%
Remission
Response
Ineffective
RUL-UB completers
88%
12%
0%
Switchers
76%
20%
4%
Total sample
81%
17%
2%
Results
Number of Treatments
During the study period 52 patients started ECT for depression out
of which 45 patients received RUL-UB. 3 patients were excluded
leaving a sample of 42 patients. Out of the 42 patients 17 patients
completed their course of ECT with RUL-UB ECT and 25 patients
completed with other types of ECT. Amongst the 25 patients who
switched 14 patients switched after 6 RUL-UB ECT treatments.
Please refer to illustrations
Discussion
Remission rates in our group as a whole was 81% with 17% showing
response. Only 2% (1/42) did not respond to the treatment. Amongst
the patients who switched, the remission rate was 76% with an
additional 20% responding to treatment. We believe the following
Loo et al suggests response might be slow with RUL-UB and it might
be prudent to wait for 6-8 treatment prior to switch (7). Mean number
of ECTs before switch was 6, however, 11 out of 25 patients had
switched before 6 sessions. When we excluded the 11 patients from
analysis, remission, response and switch rate was 48%, 6% and 46%
respectively.
The mean number of treatments in RUL-UB completers, switchers
and the entire sample were 9, 16 and 12 respectively. It could be that
switchers predominantly constitute a group of patients who are non
responsive to RUL-UB or have a more treatment resistant depression
which requires more number of ECT irrespective of the electrode
placement or pulse width used. Mean number of sessions after
switching was 9.8. While the mean number of treatments in RUL-UB
completers is comparable to other studies(7), mean number of
treatments in switchers is significantly higher than McCormick’s study
who report a mean of 11.9.
* denotes statistical significance
Total number of treatments
Method
factors – use of concurrent medications, shorter duration of current
episode, higher proportion of patients with psychotic symptoms and a
history of previous response to ECT in our sample might explain the
higher remission rates in our sample. 88% of the RUL-UB completers
remitted. This might be because 60% of the initial sample switched
and among which 60% switched due to poor or partial response.
McCormick and Loo reported 46% and 55% switch rates. Similar to
our study in McCormick’s study 60% of patients switched due to poor
response.
18
16
14
12
10
Other Pulse width or
electrode placement
No of RUL-UB
treatments
8
6
4
2
0
RUL-UB
completers
Switchers
Total sample
1. The ECT Handbook (Second edition): The Third Report of the
Royal College of Psychiatrists’ Special Committee on ECT.
2. Unützer J, Park M. Older adults with severe, treatment-resistant
depression. JAMA. 2012 Sep 5;308(9):909-18.
3. Sackheim et al..Effects of pulse width and electrode placement on
the efficacy and cognitive effects of electroconvulsive therapy. Brain
Stimulation (2008) 1, 71–83
4. Colleen Loo, Patrick Sheehan, Melissa Pigot , William Lyndon . 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
(2007) 277–281
5. Colleen K. Loo, Kirby Sainsbury, Patrick Sheehan and Bill Lyndon.
A comparison of RUL ultrabrief pulse (0.3 ms)ECT and standard RUL
ECT. International Journal of Neuropsychopharmacology (2008), 11,
883–890.
6. Laurie M. McCormick, MD, Michael C. Brumm, BS, Ajith K.
Benede, MBBS, MPH, and Jerry L. Lewis, MD. Relative Ineffectiveness of Ultrabrief Right Unilateral Versus Bilateral Electroconvulsive
Therapy in Depression. J ECT 2009;25:238-242
7. Colleen K. Loo, Natalie Katalinic, Donel Martin and Isaac Schweitzer. A review of Ultrabrief pulsewidth electroconvulsive therapy.
Therapeutic Advances in Chronic Disease 2012 3: 69

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