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Relative decrease of frontal blood flow after electroconvulsive therapy in depression distinguishes remission: a perfusion MRI study
Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Department of Psychiatry.
Department of Medical Radiation Physics, Lund University, Lund, Sweden.
Linköping University, Department of Medical and Health Sciences, Division of Radiological Sciences. Linköping University, Faculty of Medicine and Health Sciences. Department of Surgical Sciences, Radiology, Uppsala University, Uppsala, Sweden.
Department of Psychiatry, Lund University, Lund, Sweden.
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Understanding electroconvulsive therapy (ECT) is of importance not only for optimizing treatment, but could also provide important information about key features of the healing process in depression. Enhanced inhibition (the anticonvulsant hypothesis) is one of several suggested mechanisms of action of ECT. Earlier studies on cerebral blood flow during ECT have given diverging results. Our aim was to study changes in cerebral blood flow in depression treated with ECT and their relation to treatment outcome.

Methods: We obtained MRI scans in 14 depressed subjects referred for ECT. Cerebral blood flow (CBF) was measured using dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) within 1 week before and 2 weeks after a course of ECT. The relative CBF was calculated from mean values in predefined regions of interest in relation to the mean value in the whole brain.

Results: A significant relative CBF increase in the occipital region (p < 0.05) and a significant relative decrease in the right lateral temporal lobe (p < 0.05) were found in the entire study group. A significant decrease in the right frontal lobe, with a significant anteriorposterior and right-left gradient shift in relative CBF, was a distinguishing feature in patients with ECT-induced remission (n = 8).

Limitations: This observational study is limited by the risk of random bias and its low number of participants.

Conclusions: Our results suggest that a decreased relative blood flow in frontal regions may be a hallmark of treatment efficacy in depression treated with ECT.

National Category
Public Health, Global Health, Social Medicine and Epidemiology Psychiatry Neurology
Identifiers
URN: urn:nbn:se:liu:diva-121478OAI: oai:DiVA.org:liu-121478DiVA: diva2:855541
Available from: 2015-09-21 Created: 2015-09-21 Last updated: 2015-09-21Bibliographically approved
In thesis
1. On electroconvulsive therapy in depression: Clinical, cognitive and neurobiological aspects
Open this publication in new window or tab >>On electroconvulsive therapy in depression: Clinical, cognitive and neurobiological aspects
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Electroconvulsive therapy (ECT) is used worldwide to treat severe mental disorders. The most common mental disorder, and the third leading cause of disease burden in the world is depression. The clinical efficacy of ECT for severe depression is well-established. However, both the pathophysiology of depression and the mechanism of action of ECT remain elusive.

The main aims of this thesis are to address the following issues: 1) the use and practice of ECT in Sweden has not been systematically evaluated since 1975, 2) cognitive side-effects (memory disturbances) are a major concern with ECT and 3) the mechanism of action of ECT remain elusive. The neurobiological aspects of ECT focus on two hypotheses. First, the recent years´ preclinical studies that have provided evidence that ECT induces hippocampal cell proliferation, including neurogenesis. Second, that enhanced functional inhibition of neuronal activity is a key feature.

Current use and practice of ECT in Sweden (paper I) is based on data from the national quality register for ECT, the mandatory patient register of the National Board of Health and Welfare and a survey. Treated person rate (TPR) in Sweden 2013 was found to be 41 individuals / 100 000, and thus unchanged since the latest systematic investigation in Sweden 1975. In more than 70% of treatment series the indication was a depressive episode. The selection of patients for ECT and treatment technique in Sweden was similar to that in other western countries, but the consent procedure and the involvement of nurses and nursing assistants in the delivery of ECT differ. Data also shows that there is room for improvement in both the specificity of use and availability of ECT.

The second study in this thesis is a longitudinal observational trial where 12 (paper II and III) and 14 (paper IV) patients with depression referred for ECT were investigated. Patients underwent a 3 T MRI structural scanning and DSC-MRI perfusion, a neuropsychological test battery and clinical ratings before ECT, within one to two weeks after ECT and after 6 and 12 months.  In line with preclinical findings and the plasticity hypothesis of mechanism of action of ECT, the hippocampal volume increased after ECT in patients with depression. However, this increase was transient and returned to baseline levels within 6 months. No correlation was found between volumetric changes and clinical effect or cognitive outcome. Instead our results suggested an association to the number of treatments, without relation to the side of stimulation. A right-sided decrease in frontal blood flow distinguished remission from non-remission after ECT. There were significant impairments in verbal episodic memory and verbal fluency within one week after ending the ECT course, but these impairments were transient and no persistent cognitive impairments were seen during the follow-up.

In summary, this thesis present the first update on the use and practice of ECT in Sweden in the last 40 years as well as a pioneering MRI-study on the hippocampal volume increase in the treatment of depression with ECT. Supportive to earlier findings we also found the cognitive side-effects that are measurable after ECT to be transient. Furthermore, we found that a decreased frontal blood flow is of importance for the anti-depressive response to ECT.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. 68 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1468
Keyword
ECT, electroconvulsive therapy, depression, MRI, cognitive, hippocampus
National Category
Psychiatry
Identifiers
urn:nbn:se:liu:diva-121458 (URN)10.3384/diss.diva-121458 (DOI)978-91-7519-026-6 (print) (ISBN)
Public defence
2015-10-16, Berzeliussalen, Ingång 64/65, Campus US, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2015-09-21 Created: 2015-09-21 Last updated: 2016-04-06Bibliographically approved

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Nordanskog, PiaLarsson, Elna-Marie
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