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Meta-analysis of initial seizure thresholds in electroconvulsive therapy

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Abstract

In electroconvulsive therapy (ECT), electrical dosage is determined using ‘fixed-dose’, ‘age-based’ dose, or empirical titration methods. Estimation of initial seizure threshold (IST) has been claimed to be imperative for suprathreshold dosing. This systematic review aimed to determine common levels of IST, to define cut-off values for high IST, and to summarize reported IST associated factors. Medline and PsycINFO were searched from 1966 to January 2008 and relevant references were cross-checked. Subject headings including ECT, seizure threshold, dosage, and dosing were used. All articles reporting on levels of IST and/or associated factors were included. Of 395 potentially relevant reports, 46 studies on 70 samples concerning 3,023 patients were selected. Nine samples (n = 306 patients) without available standard deviation and four samples (n = 275 patients) treated with mixed electrode placement were excluded. Meta-analysis was done on 30 unilaterally treated samples (n = 1,326 patients) and 27 bilaterally treated samples (n = 1,116 patients). In unilateral ECT, weighted mean of IST was 68.2 milliCoulombs (mC; 95% CI 63.2–73.3 mC), and in bilateral ECT 111.6 mC (95% CI 103.7–119.4 mC). Calculated cut-off values for high IST were 121 mC for unilateral ECT and 221 mC for bilateral ECT. According to the literature, male gender and use of bilateral electrode placement appeared to increase IST most prominently. In conclusion, calculated electrical doses for ‘suprathreshold’ right unilateral ECT and for ‘moderate above threshold’ bilateral ECT, using commonly reported IST levels, were in the same though narrower ranges as provided in ‘fixed-dose’ and ‘half-age’ based strategies, respectively.

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References

  1. Abrams R (2002) Electroconvulsive therapy, 4th edn. Oxford University Press, New York

    Google Scholar 

  2. Abrams R (2002) Stimulus titration and ECT dosing. J ECT 18:3–9

    Article  PubMed  Google Scholar 

  3. American Psychiatric Association (2001) The practice of electroconvulsive therapy, 2nd edn. American Psychiatric Association, Washington, DC

    Google Scholar 

  4. Amiaz R, Stein O, Schreiber S, Danon PN, Dolberg OT, Grunhaus L (2001) Magnetic and seizure thresholds before and after six electroconvulsive treatments. J ECT 17:195–197

    Article  CAS  PubMed  Google Scholar 

  5. Beale MD, Kellner CH, Pritchett JT, Bernstein HJ, Burns CM, Knapp R (1994) Stimulus dose-titration in ECT: a 2-year clinical experience. Convuls Ther 10:171–176

    CAS  PubMed  Google Scholar 

  6. Boylan LS, Haskett RF, Mulsant BH, Greenberg RM, Prudic J, Spicknall K, Lisanby SH, Sackeim HA (2000) Determinants of seizure threshold in ECT: benzodiazepine use, anesthetic dosage, and other factors. J ECT 16:3–18

    Article  CAS  PubMed  Google Scholar 

  7. Chanpattana W (2001) Seizure threshold in electroconvulsive therapy: effect of instrument titration schedule. Ger J Psychiatry, pp 51–56

  8. Chanpattana W, Buppanharun W, Raksakietisak S, Vaughn MW, Somchai Chakrabhand ML (2000) Seizure threshold rise during electroconvulsive therapy in schizophrenic patients. Psychiatry Res 96:31–40

    Article  CAS  PubMed  Google Scholar 

  9. Chung KF (2002) Relationships between seizure duration and seizure threshold and stimulus dosage at electroconvulsive therapy: implications for electroconvulsive therapy practice. Psychiatry Clin Neurosci 56:521–526

    Article  PubMed  Google Scholar 

  10. Chung KF (2006) Determinants of seizure threshold of electroconvulsive therapy in Chinese. J ECT 22:100–102

    Article  PubMed  Google Scholar 

  11. Chung KF, Wong SJ (2001) Initial seizure threshold of bilateral electroconvulsive therapy in Chinese. J ECT 17:254–258

    Article  CAS  PubMed  Google Scholar 

  12. Coffey CE, Lucke J, Weiner RD, Krystal AD, Aque M (1995) Seizure threshold in electroconvulsive therapy: I. Initial seizure threshold. Biol Psychiatry 37:713–720

    Article  CAS  PubMed  Google Scholar 

  13. Coffey CE (1993) The clinical science of electroconvulsive therapy. American Psychiatric Press, Washington, DC

    Google Scholar 

  14. Colenda CC, McCall WV (1996) A statistical model predicting the seizure threshold for right unilateral ECT in 106 patients. Convuls Ther 12:3–12

    CAS  PubMed  Google Scholar 

  15. Delva NJ, Brunet D, Hawken ER, Kesteven RM, Lawson JS, Lywood DW, Rodenburg M, Waldron JJ (2000) Electrical dose and seizure threshold: relations to clinical outcome and cognitive effects in bifrontal, bitemporal, and right unilateral ECT. J ECT 16:361–369

    Article  CAS  PubMed  Google Scholar 

  16. Dolin SJ, Hunter AB, Halsey MJ, Little HJ (1988) Anticonvulsant profile of the dihydropyridine calcium channel antagonists, nitrendipine and nimodipine. Eur J Pharmacol 152:19–27

    Article  CAS  PubMed  Google Scholar 

  17. Enns M, Karvelas L (1995) Electrical dose titration for electroconvulsive therapy: a comparison with dose prediction methods. Convuls Ther 11:86–93

    CAS  PubMed  Google Scholar 

  18. Fink M, Petrides G, Kellner C, Mueller M, Knapp R, Husain MM, Rasmussen K, Rummans T, O’Connor K (2008) Change in seizure threshold during electroconvulsive therapy. J ECT 24:114–116

    Article  PubMed  Google Scholar 

  19. Gilabert E, Rojo E, Vallejo J (2004) Augmentation of electroconvulsive therapy seizures with sleep deprivation. J ECT 20:242–247

    Article  PubMed  Google Scholar 

  20. Girish K, Gangadhar BN, Janakiramaiah N, Lalla RK (2003) Seizure threshold in ECT: effect of stimulus pulse frequency. J ECT 19:133–135

    Article  CAS  PubMed  Google Scholar 

  21. Girish K, Mayur PM, Saravanan ES, Janakiramaiah N, Gangadhar BN, Subbakrishna DK, Rao GS (2000) Seizure threshold estimation by formula method: a prospective study in unilateral ECT. J ECT 16:258–262

    Article  CAS  PubMed  Google Scholar 

  22. Heikman P, Kalska H, Katila H, Sarna S, Tuunainen A, Kuoppasalmi K (2002) Right unilateral and bifrontal electroconvulsive therapy in the treatment of depression: a preliminary study. J ECT 18:26–30

    Article  PubMed  Google Scholar 

  23. Heikman P, Katila H, Sarna S, Wahlbeck K, Kuoppasalmi K (2002) Differential response to right unilateral ECT in depressed patients: impact of comorbidity and severity of illness [ISRCTN39974945]. BMC Psychiatry 2:2

    Article  PubMed  Google Scholar 

  24. Heikman P, Tuunainen A, Kuoppasalmi K (1999) Value of the initial stimulus dose in right unilateral and bifrontal electroconvulsive therapy. Psychol Med 29:1417–1423

    Article  CAS  PubMed  Google Scholar 

  25. Heikman P, Tuunainen A, Sailas E, Kuoppasalmi K (2003) Seizures induced by low-dose right unilateral and bifrontal electroconvulsive stimuli. J ECT 19:189–193

    Article  PubMed  Google Scholar 

  26. Hillbom M, Pieninkeroinen I, Leone M (2003) Seizures in alcohol-dependent patients: epidemiology, pathophysiology and management. CNS Drugs 17:1013–1030

    Article  CAS  PubMed  Google Scholar 

  27. Kellner CH (2001) Towards the modal ECT treatment. J ECT 17:1–2

    Article  CAS  PubMed  Google Scholar 

  28. Khalid N, Atkins M, Kirov G (2006) The effects of etomidate on seizure duration and electrical stimulus dose in seizure-resistant patients during electroconvulsive therapy. J ECT 22:184–188

    Article  CAS  PubMed  Google Scholar 

  29. Kotresh S, Girish K, Janakiramaiah N, Rao GU, Gangadhar BN (2004) Effect of ECT stimulus parameters on seizure physiology and outcome. J ECT 20:10–12

    Article  CAS  PubMed  Google Scholar 

  30. Krystal AD, Coffey CE, Weiner RD, Holsinger T (1998) Changes in seizure threshold over the course of electroconvulsive therapy affect therapeutic response and are detected by ictal EEG ratings. J Neuropsychiatry Clin Neurosci 10:178–186

    CAS  PubMed  Google Scholar 

  31. Krystal AD, Dean MD, Weiner RD, Tramontozzi LAIII, Connor KM, Lindahl VH, Massie RW (2000) ECT stimulus intensity: are present ECT devices too limited? Am J Psychiatry 157:963–967

    Article  CAS  PubMed  Google Scholar 

  32. Laidlaw J, Bentham P, Khan P, Staples V, Dhariwal A, Coope B, Day E, Fear C, Marley C, Stemman J (2000) A comparison of stimulus dosing methods for electroconvulsive therapy. Psychiatr Bull 24:184–187

    Article  Google Scholar 

  33. Lisanby SH, Devanand DP, Prudic J, Pierson D, Nobler MS, Fitzsimons L, Sackeim HA (1998) Prolactin response to electroconvulsive therapy: effects of electrode placement and stimulus dosage. Biol Psychiatry 43:146–155

    Article  CAS  PubMed  Google Scholar 

  34. Lisanby SH, Luber B, Schlaepfer TE, Sackeim HA (2003) Safety and feasibility of magnetic seizure therapy (MST) in major depression: randomized within-subject comparison with electroconvulsive therapy. Neuropsychopharmacology 28:1852–1865

    Article  PubMed  Google Scholar 

  35. Luchowska E, Luchowski P, Wielosz M, Kleinrok Z, Czuczwar SJ, Urbanska EM (2002) Propranolol and metoprolol enhance the anticonvulsant action of valproate and diazepam against maximal electroshock. Pharmacol Biochem Behav 71:223–231

    Article  CAS  PubMed  Google Scholar 

  36. Mayur PM, Gangadhar BN, Janakiramaiah N, Subbakrishna DK (1999) Motor seizure monitoring during electroconvulsive therapy. Br J Psychiatry 174:270–272

    Article  CAS  PubMed  Google Scholar 

  37. McCall WV, Dunn A, Rosenquist PB, Hughes D (2002) Markedly suprathreshold right unilateral ECT versus minimally suprathreshold bilateral ECT: antidepressant and memory effects. J ECT 18:126–129

    Article  PubMed  Google Scholar 

  38. McCall WV, Reboussin DM, Weiner RD, Sackeim HA (2000) Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy: acute antidepressant and cognitive effects. Arch Gen Psychiatry 57:438–444

    Article  CAS  PubMed  Google Scholar 

  39. McCall WV, Shelp FE, Weiner RD, Austin S, Norris J (1993) Convulsive threshold differences in right unilateral and bilateral ECT. Biol Psychiatry 34:606–611

    Article  CAS  PubMed  Google Scholar 

  40. McCall WV, Sparks W, Jane J, Rosenquist PB, Colenda CC, Reboussin DM (1998) Variation of ictal electroencephalographic regularity with low-, moderate-, and high-dose stimuli during right unilateral electroconvulsive therapy. Biol Psychiatry 43:608–611

    Article  CAS  PubMed  Google Scholar 

  41. McCall WV, Weiner RD, Carroll BJ, Shelp FE, Ritchie JC, Austin S, Norris J (1996) Serum prolactin, electrode placement, and the convulsive threshold during ECT. Convuls Ther 12:81–85

    CAS  PubMed  Google Scholar 

  42. Mukherjee S, Sackeim HA, Schnur DB (1994) Electroconvulsive therapy of acute manic episodes: a review of 50 years’ experience. Am J Psychiatry 151:169–176

    CAS  PubMed  Google Scholar 

  43. Ng C, Schweitzer I, Alexopoulos P, Celi E, Wong L, Tuckwell V, Sergejew A, Tiller J (2000) Efficacy and cognitive effects of right unilateral electroconvulsive therapy. J ECT 16:370–379

    Article  CAS  PubMed  Google Scholar 

  44. Nobler MS, Luber B, Moeller JR, Katzman GP, Prudic J, Devanand DP, Dichter GS, Sackeim HA (2000) Quantitative EEG during seizures induced by electroconvulsive therapy: relations to treatment modality and clinical features. I. Global analyses. J ECT 16:211–228

    Article  CAS  PubMed  Google Scholar 

  45. Patel AS, Gorst-Unsworth C, Venn RM, Kelley K, Jacob Y (2006) Anesthesia and electroconvulsive therapy: a retrospective study comparing etomidate and propofol. J ECT 22:179–183

    Article  PubMed  Google Scholar 

  46. Perera TD, Luber B, Nobler MS, Prudic J, Anderson C, Sackeim HA (2004) Seizure expression during electroconvulsive therapy: relationships with clinical outcome and cognitive side effects. Neuropsychopharmacology 29:813–825

    Article  PubMed  Google Scholar 

  47. Petrides G, Fink M (1996) The “half-age” stimulation strategy for ECT dosing. Convuls Ther 12:138–146

    CAS  PubMed  Google Scholar 

  48. Pisani F, Oteri G, Costa C, Di RG, Di PR (2002) Effects of psychotropic drugs on seizure threshold. Drug Saf 25:91–110

    Article  CAS  PubMed  Google Scholar 

  49. Poulet E (1998) Quantité d’energie optimale à délivrer au cours du traitement ECT: titration ou méthode “âge-dose”? Université Victor-Segalen Bordeaux 2, Thesis

  50. Ranjkesh F, Barekatain M, Akuchakian S (2005) Bifrontal versus right unilateral and bitemporal electroconvulsive therapy in major depressive disorder. J ECT 21:207–210

    Article  PubMed  Google Scholar 

  51. Rasmussen KG, Zorumski CF, Jarvis MR (1994) Possible impact of stimulus duration on seizure threshold in ECT. Convuls Ther 10:177–180

    CAS  PubMed  Google Scholar 

  52. Rosa MA, Rosa MO, Daltio CS, Abreu LN, Marcolin MA (2006) Open trial on the efficacy of right unilateral electroconvulsive therapy with titration and high charge. J ECT 22:237–239

    Article  PubMed  Google Scholar 

  53. Sackeim H, Decina P, Prohovnik I, Malitz S (1987) Seizure threshold in electroconvulsive therapy. Effects of sex, age, electrode placement, and number of treatments. Arch Gen Psychiatry 44:355–360

    CAS  PubMed  Google Scholar 

  54. Sackeim HA (1999) The anticonvulsant hypothesis of the mechanisms of action of ECT: current status. J ECT 15:5–26

    CAS  PubMed  Google Scholar 

  55. Sackeim HA, Devanand DP, Prudic J (1991) Stimulus intensity, seizure threshold, and seizure duration: impact on the efficacy and safety of electroconvulsive therapy. Psychiatr Clin North Am 14:803–843

    CAS  PubMed  Google Scholar 

  56. Sackeim HA, Long J, Luber B, Moeller JR, Prohovnik I, Devanand DP, Nobler MS (1994) Physical properties and quantification of the ECT stimulus: I. Basic principles. Convuls Ther 10:93–123

    CAS  PubMed  Google Scholar 

  57. Sackeim HA, Luber B, Katzman GP, Moeller JR, Prudic J, Devanand DP, Nobler MS (1996) The effects of electroconvulsive therapy on quantitative electroencephalograms. Relationship to clinical outcome. Arch Gen Psychiatry 53:814–824

    CAS  PubMed  Google Scholar 

  58. Sackeim HA, Prudic J, Devanand DP, Kiersky JE, Fitzsimons L, Moody BJ, McElhiney MC, Coleman EA, Settembrino JM (1993) Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med 328:839–846

    Article  CAS  PubMed  Google Scholar 

  59. Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, Fitzsimons L, Moody BJ, Clark J (2000) A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 57:425–434

    Article  CAS  PubMed  Google Scholar 

  60. Sackeim HA, Prudic J, Nobler MS, Fitzsimons L, Lisanby SH, Payne N, Berman RM, Brakemeier E-L, Perera TD, Devanand DP (2008) Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. Brain Stimulation 1:71–83

    Article  PubMed  Google Scholar 

  61. Scott AI, Boddy H (2000) The effect of repeated bilateral electroconvulsive therapy on seizure threshold. J ECT 16:244–251

    Article  CAS  PubMed  Google Scholar 

  62. Scott AI, Boddy H (2002) Induction agents in electroconvulsive therapy: a comparison of methohexitone and propofol. Psychiatr Bull 26:455–457

    Article  Google Scholar 

  63. Scott AI, Dykes S (1999) Initial seizure threshold in the clinical practice of bilateral electroconvulsive therapy in Edinburgh, Scotland. J ECT 15:118–124

    CAS  PubMed  Google Scholar 

  64. Shapira B, Lidsky D, Gorfine M, Lerer B (1996) Electroconvulsive therapy and resistant depression: clinical implications of seizure threshold. J Clin Psychiatry 57:32–38

    CAS  PubMed  Google Scholar 

  65. Swartz CM (2006) Electroconvulsive therapy stimulus dose expressed as volume of seizure foci. J ECT 22:54–58

    Article  PubMed  Google Scholar 

  66. Tiller JW, Ingram N (2006) Seizure threshold determination for electroconvulsive therapy: stimulus dose titration versus age-based estimations. Aust N Z J Psychiatry 40:188–192

    Article  PubMed  Google Scholar 

  67. Waarde JA, van Muller METM, Verwey B, Mast RC, van der (2009) Exceptionally high initial seizure threshold in a catatonic patient. J ECT (in press)

  68. Weiner RD (1997) Stimulus dosing with ECT: to titrate or not to titrate–that is the question. Convuls Ther 13:7–9

    CAS  PubMed  Google Scholar 

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Acknowledgments

The authors thank E. Roovers, PhD, epidemiologist (Alysis Zorggroep, Arnhem, the Netherlands) for methodological and statistical assistance, and W.W. van den Broek, MD, PhD (Erasmus University Medical Center, Rotterdam, the Netherlands) for his comments on the manuscript.

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The authors declare that they have no conflicts of interests.

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Authors and Affiliations

  1. Alysis Zorggroep, Rijnstate Hospital, P.O. Box 9555, 6800 TA, Arnhem, The Netherlands

    Jeroen A. van Waarde & Bastiaan Verwey

  2. Leiden University Medical Center, Leiden, The Netherlands

    Rose C. van der Mast

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  1. Jeroen A. van Waarde
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  2. Bastiaan Verwey
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  3. Rose C. van der Mast
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Correspondence to Jeroen A. van Waarde.

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van Waarde, J.A., Verwey, B. & van der Mast, R.C. Meta-analysis of initial seizure thresholds in electroconvulsive therapy. Eur Arch Psychiatry Clin Neurosci 259, 467–474 (2009). https://doi.org/10.1007/s00406-009-0011-7

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