Electroconvulsive therapy for depression and ketamine for relapse prevention: factors affecting response, cognition and research participation

Abstract

This thesis comprises five clinical research studies. Study 1. Pilot randomised controlled trial: Ketamine vs midazolam for depression relapse prevention following successful electroconvulsive therapy (ECT), the KEEPWELL Trial (NCT02414932) The objective of this study was to conduct a randomised controlled pilot trial of a fourweek course of once-weekly ketamine or midazolam infusions for relapse prevention following ECT for depression to assess trial procedures for feasibility for a future definitive trial. Forty-three participants were recruited to a monitoring phase but only six of these were eligible and agreeable to randomised treatment. No participant completed the treatment protocol. The study found that the trial protocol is not feasible and therefore not suitable for a definitive trial. Future studies could consider open-label treatment, recruitment of participants who live very nearby. Study 2. Prospective cohort study: Effects of mood and time on autobiographical memory before and after electroconvulsive therapy for depression This study aimed to examine performance on the full Kopelman Autobiographical Memory Interview in severely depressed patients (n=27) before and after a course of ECT and to compare this with the performance of healthy controls (n=72) before and after a 4-week interval. I found that autobiographical memory is profoundly impaired in depressed people and that the Kopelman Autobiographical Memory Interview is likely not adequately sensitive to change to identify any overall change in autobiographical memory performance after ECT. v Study 3. Prospective cohort study: Effect of personality disorder on response to ECT for depression: a prospective cohort study The aim of this study was to assess for association between scores on the brief personality screening tool, the self-reported Standardised Assessment of Personality – Abbreviated Scale (SAPAS) and response to ECT among patients with unipolar major depressive disorder (n=49). I found that while the presence of likely personality disorder on the SAPAS was associated with lower ECT response rate, it is unlikely to contribute to cognitive impairment. Study 4. Prospective cohort study: Childhood trauma and response to ECT for depression: a prospective cohort study This study aimed to examine report of childhood trauma and recent trauma in a severely depressed population referred for ECT (n=44) and assess for association between presence of childhood or recent trauma and response to ECT. I found that both childhood and recent trauma were common in depressed people having ECT and that the presence of childhood trauma is associated with reduced response rate to ECT. Study 5. Retrospective chart review: Involuntary and voluntary electroconvulsive therapy: a case-control study In this study I compared courses of involuntary ECT (n=48) with matched voluntary ECT courses (n=96) in terms of clinical and demographic factors, treatment requirements, and outcomes. I found that the groups were similar in many respects and results of clinical ECT research can therefore be generalised to people having involuntary ECT.