Effects of electroconvulsive
therapy for depression on health
related quality of life
Adam Kavanagh
Acknowledgements
• Prof. Declan McLoughlin
• Dr. Maria Semkovska, Dr. Ross Dunne, Dr.
Martha Noone, Dr. Erik Kolshus, Ana Jelovac,
Sinead Lambe, Mary Carton
• Shane McCarron, Ger Ryan, Lucy Kiely
Presentation outline
• Depression
• Electroconvulsive therapy
• Aim
• Methodology
• Results
Depression
Low mood or
Anhedonia
Weight
Sleep
Concentration
Psychomotor agitation/ retardation
Fatigue
Worthlessness/ guilt
Suicidal thoughts
The symptoms
cause clinically
significant
impairment in
functioning
• 7% - 12% for men
• 20% - 25% for women
• 4th highest contributor to total burden of disease
• 2nd leading cause of disability by 2020
Electroconvulsive therapy
Kavanagh & McLoughlin 2009
Aim
• The aim of this study was to compare the
effects of 1.5 × ST bitemporal and high dose
(6 × ST) RUL ECT administered twice weekly
on Health related quality of life (HRQOL)
Methodology
• EFFECT-DEP TRIAL (ISRCTN23577151)
– Design
– Location
– Inclusion/ Exclusion
– Randomization
– Primary outcome
– Power
SF-36
•
•
•
•
•
A generic outcome measure
Subjectively rated
Only 36 questions
8-scale profile of functional health and well-being
Psychometrically-based physical and mental
health summary measures
• Normative data
• Sensitive to change
• Most frequently used patient rated outcome
measure used in clinical trials (Scoggins & Patrick
2009)
Results
Results
High-dose RUL
Bitemporal
Mean (SD)
Mean (SD)
56.7 (15.0)
59.1 (13.8)
29 (58%)
31 (62%)
Baseline HDRS
30.3 (6.8)
29.3 (7.0)
0.720 (98)
P = 0.473
Baseline BDI II
32.1 (11.9)
37.2 (13.6)
-1.515 (56)
P = 0.135
Psychotic
8 (16%)
6 (12%)
0.500 (1)
P = 0.479
Treatment
25 (50%)
30 (60%)
0.646 (1)
P = 0.421
22 (44%)
20 (40%)
0.041 (1)
P = 0.839
t-test (d.f.)
χ²-test (d.f.)
P
Demographic
details
Age
Female
-1.173 (98)
P = 0.244
0.167 (1)
P = 0.683
Clinical details
resistant
Previous ECT
Pre-treatment N (RUL = 36, Bi = 32),
6 months N (RUL = 26, bi = 28),
Completed both assessments (RUL = 21, Bi = 22)
Pre-treatment N (RUL = 36, Bi = 32),
6 months N (RUL = 26, bi = 28),
Completed both assessments (RUL = 21, Bi = 22)
HRQOL 6 months after
ECT for severe depression
compared to “normal”
population
Predicting HRQOL 6 months after
ECT for severe depression
Linear model

MCS score =
Treatment parameters (Laterality, dose, seizure duration)
+ Patient characteristics (Gender, age)
+ Clinical details (Medications, resistance, remission status,
cognitive functioning)
Remission status at EOT
Summary
• Depression significantly impacts HRQOL
• ECT is associated with improvements in
subjectively assessed HRQOL
• High dose RUL ECT is as effective as standard
bitemporal ECT
• Persistent deficits 6 months after treatment
• Remission status at EOT explained persistent
deficits
Strengths & limitations
• Strengths
–
–
–
–
–
Randomized design
Large sample size
New information about HDRUL ECT
Generalizable results
No difference between participants that completed
assessments and those that did not
– Robust outcomes measure
– Robust data analysis approach
• Limitations
– Loss of data at 6 months
Health related quality of life
• HRQOL – depression
• HRQOL – depression and ECT
• HRQOL – depression and ECT and NICE ‘03 + ‘09
Freeman et
40
al (1978)
Lambourn
& Gill
(1978)
Johnstone
et al (1980)
32
70
Double
blind Partial
course

HDRS

Double
blind
 
HDRS

Double
blind
 

Double
blind
 

Double
blind
 

Double
blind
 
Regular
Sine Treating
medications
wave clinical Twice
maintained
team weekly
during trial
Benzodiazepines Brief Treating Thrice
only
pulse clinical weekly
team
Benzodiazepines Sine Treating Twice
only
Wave clinical weekly
team
50mg
Sine Treating Twice
amitriptyline at wave clinical weekly
night
team
Benzodiazepines Sine Treating Twice
only
wave clinical weekly
team
Benzodiazepines Sine Treating
only
wave clinical Twice
team weekly
Laterality
Frequency of
treatment
Treatment
terminated by
Wave form
Medication
use during
trial
Sham
comparison
group
Remission
criteria
Blinding
HDRS

Visual
22 analogue
scale
HDRS
Brandon et
77
&
al (1984)
MADRS
MADRS
Gregory et
69
&
al (1985)
HDRS
West (1981)
Random
allocation
Depression
severity scale
N
Bilateral
Right
Unilateral
Bifrontal
Bilateral
Bilateral
Bilateral
and right
unilateral
groups
Electroconvulsive therapy
• The UK ECT Review Group (2003) - meta-analysis:
– Real ECT more effective than simulated ECT:
– 9·7 point difference in HDRS
• Janicak et al (1985) – Meta-analysis:
– MAOI – ECT more effective by 45%
– Tricyclic – ECT more effective by 20%
• SSRI – ECT significantly more effective than
Paroxetine (Folkerts et al. 1997):
– 59% Vs reduction 29% reduction in HDRS score.