Catatonia, Depression - Major Depressive Disorder
Conditions
Keywords
electroconvulsive therapy
Brief summary
The goal of this clinical trial is to improve how electroconvulsive therapy (ECT) stimulation settings are chosen. Researchers will use real-time brain monitoring to measure both seizures and a recently identified brain event called cortical spreading depolarization (CSD). The main questions it aims to answer are: What is the best way to increase ECT stimulation settings? How do different pulse settings affect the brain's response? Can certain settings produce CSD without causing a seizure? Participants already receiving ECT as part of their care will take part. They will be assigned to one of two groups: Index ECT group: Participants starting ECT will receive different standard titration approaches. Maintenance ECT group: Participants receiving ongoing ECT will undergo a brief, low-dose stimulation test before treatment. All participants will be monitored using brain physiology (EEG and blood flow) and symptom scales during treatment.
Detailed description
This is an exploratory, single-center open-label clinical trial at Pennsylvania Hospital (PAH) intended to optimize stimulation settings for electroconvulsive therapy (ECT), guided by real-time monitoring of both seizure and a recently discovered postictal event: cortical spreading depolarization (CSD). We will address three key questions: 1. What is the best strategy for up-titrating settings for ECT?; 2. How do individual pulse parameters impact brain evoked response?; 3. Are there stimulation settings that directly induce CSD waves without seizure? This study will take place in the context of routine treatments for patients already consenting to receive ECT for a wide range of clinical indications. Patients will be enrolled in one of two arms: 1. Index Titration Arm: Patients coming in for initial index ECT courses (acute phase) will be randomized to one of several stimulation parameter titration tables while receiving otherwise routine ECT care. 2. Maintenance Arm: In clinically stable patients receiving monthly maintenance ECT, a sub-convulsive stimulation settings ramp will be performed under anesthesia immediately preceding their regular ECT treatment. All patients being treated with ECT at PAH are eligible for this study. Outcomes will include non-invasive monitoring of brain hemodynamics and EEG as well as clinical symptom scales.
Interventions
PROCEDUREElectroconvulsive Therapy
Electrical stimulation under anesthesia
Sponsors
University of Pennsylvania
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Outcomes Assessor)
Intervention model description
All patients are treated with ECT using different stimulation parameters
Eligibility
Sex/Gender
ALL
Healthy volunteers
No
Inclusion criteria
* Any patients being treated with electroconvulsive therapy at Pennsylvania Hospital who are willing and able to participate are eligible to be subjects in this study.
Exclusion criteria
1. They are unwilling or unable to consent first to the SWEET COMBO protocol for optical monitoring during ECT 2. Clinically significant psychiatric comorbidity as determined by clinical interview and in the opinion of the Investigator and clinical team would alter the risk/benefit of the study 3. History of poor response to ECT treatment in the opinion of the Investigator and clinical team that would alter the risk/benefit of the study 4. Presence of any disease, medical condition or physical condition that, in the opinion of the Investigator, may compromise, interfere with, limit, affect or reduce the: 1. subject's ability to participate safely in the study 2. integrity of the data or 3. subject's ability to complete the full duration of the study.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Brain hemodynamics | Periprocedural (10-20 minutes per ECT session). Assessed repeatedly over approximately 12 ECT sessions for index arm patients (3 times/week for 4-6 weeks), or for 8 sessions (once a month for 8 months) in the maintenance arm. | Functional near infrared spectroscopy imaging will be performed during each ECT treatment, from which we will extract oxy- and deoxyhemoglobin concentrations (in mM) over time. |
| Electroencephalography - Seizure Duration | Periprocedural (10-20 minutes per ECT session). Assessed repeatedly over approximately 12 ECT sessions for index arm patients (3 times/week for 4-6 weeks), or for 8 sessions (once a month for 8 months) in the maintenance arm. | Bilateral EEG over FP1 and FP2 zones, from which we will compute seizure duration (in seconds) |
| Electroencephalography - theta band power | Periprocedural (10-20 minutes per ECT session). Assessed repeatedly over approximately 12 ECT sessions for index arm patients (3 times/week for 4-6 weeks), or for 8 sessions (once a month for 8 months) in the maintenance arm. | Bilateral EEG over FP1 and FP2 zones, from which we will compute theta band power (in dB) |
| Electroencephalography - Brain Symmetry Index | Periprocedural (10-20 minutes per ECT session). Assessed repeatedly over approximately 12 ECT sessions for index arm patients (3 times/week for 4-6 weeks), or for 8 sessions (once a month for 8 months) in the maintenance arm. | Bilateral EEG over FP1 and FP2 zones, from which we will compute brain symmetry index (unitless) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Single Letter Fluency | Administered pre-procedurally at baseline and prior to every ECT treatment for index arm patients (12 treatments, 3 times weekly for for 4-6 weeks), or once monthly (for 8 months) in maintenance arm patients. | Test of verbal fluency. Unit is number of words starting with a given letter provided in a one minute period. |
| Psychotic Depression Assessment Scale (PDAS) | Administered pre-procedurally at baseline and once weekly for index arm patients (for 4-6 weeks), or once monthly (for 8 months) in maintenance arm patients | Psychosis rating scale for patients with psychosis, to be administered by clinical team. Unitless, ranging from 0-44. |
| 3 word registration and recall | Administered pre-procedurally at baseline and prior to every ECT treatment for index arm patients (12 treatments, 3 times weekly for for 4-6 weeks), or once monthly (for 8 months) in maintenance arm patients. | Test of short term memory. Unit is number (out of 3) words registered and repeated back at 0 minutes, and the same at 3 minutes delay. |
| Clinical Global Impressions Scale for Severity and Improvement | Administered pre-procedurally at baseline and prior to every ECT treatment for index arm patients (12 treatments, 3 times weekly for for 4-6 weeks), or once monthly (for 8 months) in maintenance arm patients. | To be determined by clinical team. Unitless, ranging from 0-7. |
| Quick Inventory of Depression Self-Report | Administered pre-procedurally at baseline and once weekly for index arm patients (for 4-6 weeks), or once monthly (for 8 months) in maintenance arm patients. | Depression symptom scale filled out by patient. Unitless, ranging from 0-27. |
| Bush Francis Catatonia Rating Scale | Administered pre-procedurally at baseline and prior to every ECT treatment for index arm patients (12 treatments, 3 times weekly for for 4-6 weeks), or once monthly (for 8 months) in maintenance arm patients. | Catatonia rating scale conducted by clinical team. Unitless, ranging from 0-69. |
Countries
United States
Contacts
CONTACTZachary Rosenthal, MD PhD
CONTACTMario Cristancho, MD
Outcome results
None listed