Ute Kessler

Background: Electroconvulsive therapy (ECT) is a safe and effective medical treatment, yet provision varies internationally. We provide an up-to-date review of ECT practice in Nordic and western European countries. Methods: European experts contributed data from peer-reviewed literature, governmental publications, unpublished administrative datasets, and hitherto unpublished surveys. The primary outcome was the number of individuals treated with ECT in each country per year. Primary analysis compared the annual treated person rate per million population in the most recent year since 2015 for which data were available. Secondary analysis compared trends in rates over 25 years, in countries for which a reliable outcome was available at two or more time points. Results: Across 15 countries, 12 had data meeting primary analysis criteria. Of these, all Nordic countries had annual treated patient rates per million population over 200, Italy 2.7, and other western European countries between 30 and 100. German-, Dutch-, and French-speaking countries saw increases in ECT use over 25 years, while English-speaking countries exhibited declines. Unilateral placement varied from 16% of treatments in the United Kingdom to 79% in Norway. Everywhere, most ECT was given for depressive episodes. Conclusions: Although the optimal rate of use is unknown, widely differing rates across European nations suggest ECT is underused in some high-income countries, depriving patients of vital medical care. The European ECT community must support the development of reliable data collection on usage across the continent and service improvement where provision is underdeveloped, to ensure appropriate treatment is offered to all patients for whom it is indicated.

Electroconvulsive therapy (ECT) is an effective antidepressant treatment. The mechanisms behind the therapeutic effect are not fully understood, and reliable biomarkers for response are needed. Epigenetic modifications, such as DNA methylation (DNAm), can reflect both genetic and environmental impacts; they may shed light on the mechanisms behind treatment effects and they have the potential to inform response prediction. We performed an epigenome-wide association study (EWAS) in peripheral blood from patients before and after ECT in a Norwegian cohort (n = 65). The methylation levels of 12 differentially methylated CpG positions (DMPs) and 18 differentially methylated regions (DMRs) were significantly associated with percent clinical response. In addition, 29 DMPs and 23 DMRs were significantly associated with remission (Montgomery and Åsberg Depression Rating Scale MADRS < 10 post treatment). Two DMRs were also significantly associated with percent response at baseline and four DMRs were significantly associated with remission at baseline (FDR < 0.05). We did not identify any longitudinal (pre-post) changes in DNAm. We further performed the first meta-analysis (n = 99) between ECT cohorts, combining this Norwegian cohort and a German ECT cohort (n = 34). Seven of the DMRs found to be associated with response in the meta-analyses were previously identified in the Norwegian or the German cohort (FDR < 0.05). Methylation risk scores (MS) calculated using DMPs associated with ECT in the Norwegian cohort showed promising association with response to ECT in the German cohort (p = 0.06). Finally, we found increased neutrophil to lymphocyte ratios, calculated from estimated cell proportions, to be associated with remission (p < 0.003) in the Norwegian cohort.

Electroconvulsive therapy (ECT) is an established treatment for depression, but more data on effectiveness and safety in clinical practice is needed. The aim of this register-based study was to investigate short-term effectiveness and cognitive safety after ECT, evaluated by clinicians and patients. Secondary, we investigated predictors for remission and cognitive decline. The study included 392 patients from the Regional Register for Neurostimulation Treatment in Western Norway. Depressive symptoms and cognitive function were assessed with Montgomery-Åsberg Depression Rating Scale and Mini-Mental State Examination (clinician-rated) and Beck Depression Inventory and Everyday Memory Questionnaire (patient-rated). Assessments were done prior to ECT-series and a mean of 1.7 days after (range 6 days before and 12 days after) end of ECT-series. Paired samples t-tests were extended by detailed, clinically relevant subgroups. Predictors were examined using logistic regression. Clinician- and patient-rated remission rates were 49.5 and 41.0%, respectively. There was a large reduction in depressive symptoms and a small improvement in cognition after ECT, but we also identified subgroups with non-response of ECT in combination with cognitive decline (4.6% clinician-rated, 15.7% patient-rated). Positive predictors for patient- and clinician-rated remission were increasing age, shorter duration of depressive episode, and psychotic features. Antipsychotic medication at the commencement of treatment and previous ECT-treatment gave higher odds of clinician-rated remission, whereas higher pretreatment subjective depression level was associated with lower odds for patient-rated remission. Clinician-rated cognitive decline was predicted by higher pretreatment MMSE scores, whereas psychotic features, increasing age, and greater pretreatment subjective memory concerns were associated with lower odds for patient-rated cognitive decline. Our study supports ECT as an effective and safe treatment, although subgroups have a less favorable outcome. ECT should be considered at an early stage for older patients suffering from depression with psychotic features. Providing comprehensive and balanced information from clinicians and patients perspectives on effects and side effects, may assist in a joint consent process.

Neurostimulation is a mainstream treatment option for major depression. Neuromodulation techniques apply repetitive magnetic or electrical stimulation to some neural target but significantly differ in their invasiveness, spatial selectivity, mechanism of action, and efficacy. Despite these differences, recent analyses of transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS)-treated individuals converged on a common neural network that might have a causal role in treatment response. We set out to investigate if the neuronal underpinnings of electroconvulsive therapy (ECT) are similarly associated with this causal depression network (CDN). Our aim here is to provide a comprehensive analysis in three cohorts of patients segregated by electrode placement (N = 246 with right unilateral, 79 with bitemporal, and 61 with mixed) who underwent ECT. We conducted a data-driven, unsupervised multivariate neuroimaging analysis Principal Component Analysis (PCA) of the cortical and subcortical volume changes and electric field (EF) distribution to explore changes within the CDN associated with antidepressant outcomes. Despite the different treatment modalities (ECT vs TMS and DBS) and methodological approaches (structural vs functional networks), we found a highly similar pattern of change within the CDN in the three cohorts of patients (spatial similarity across 85 regions: r = 0.65, 0.58, 0.40, df = 83). Most importantly, the expression of this pattern correlated with clinical outcomes (t = −2.35, p = 0.019). This evidence further supports that treatment interventions converge on a CDN in depression. Optimizing modulation of this network could serve to improve the outcome of neurostimulation in depression.

Neurostimulation is a mainstream treatment option for major depression. Neuromodulation techniques apply repetitive magnetic or electrical stimulation to some neural target but significantly differ in their invasiveness, spatial selectivity, mechanism of action, and efficacy. Despite these differences, recent analyses of transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS)-treated individuals converged on a common neural network that might have a causal role in treatment response. We set out to investigate if the neuronal underpinnings of electroconvulsive therapy (ECT) are similarly associated with this common causal network (CCN). Our aim here is to provide a comprehensive analysis in three cohorts of patients segregated by electrode placement (N = 246 with right unilateral, 79 with bitemporal, and 61 with mixed) who underwent ECT. We conducted a data-driven, unsupervised multivariate neuroimaging analysis (Principal Component Analysis, PCA) of the cortical and subcortical volume changes and electric field (EF) distribution to explore changes within the CCN associated with antidepressant outcomes. Despite the different treatment modalities (ECT vs TMS and DBS) and methodological approaches (structural vs functional networks), we found a highly similar pattern of change within the CCN in the three cohorts of patients (spatial similarity across 85 regions: r = 0.65, 0.58, 0.40, df = 83). Most importantly, the expression of this pattern correlated with clinical outcomes. This evidence further supports that treatment interventions converge on a CCN in depression. Optimizing modulation of this network could serve to improve the outcome of neurostimulation in depression.