Electroconvulsive therapy (ECT) is used to treat people with severe depression. During ECT, the brain is given electric pulses that cause a seizure. Although it is effective, it can cause side effects, including memory loss. Researchers want to study a new way to give ECT called iLAST.
To see if iLAST is safe and feasible in treating depression.
People ages 22 70 years old who have major depressive disorder and are eligible for ECT
Participants will be screened under protocol 01-M-0254. This includes:
Medical and psychiatric history and exam
Blood and urine tests
Participants will be inpatients at the Clinical Center. They study has 3 phases and will last up to 20 weeks.
Phase I will last 1 week. It includes:
MRI: Participants will lie in a scanner that takes pictures of the body
MEG: A cone over the participant s head will record brain activity.
TMS: A wire coil placed on the participant s scalp will produce an electrical current to affect brain activity.
SEP: An electrode on the participant s wrist will give a small electrical shock to test nerve function.
Phase II will last 2 and a half weeks. It includes:
Seven sessions of iLAST under general anesthesia. Participants may also get standard ECT.
EEG: A small electrode placed on the participant s scalp will record brain waves.
Interviews about mood, symptoms, and side effects. Participants facial expressions may be video recorded.
Phase III will last at least 1 week. It will include:
Standard ECT if needed. Participants will have sessions every other day, 3 times a week.
Sponsoring Institution: National Institute of Mental Health
Despite advances in antidepressant interventions, none has replaced electroconvulsive therapy (ECT) in its acute efficacy and spectrum of action in severely depressed patients, including in psychotic depression, catatonia, and acutely suicidal patients. However, ECT carries a risk of significant adverse effects including cognitive and physiological side effects, some of which can be long term. The side effects are thought to be related to stimulation of brain areas beyond those implicated in depression, so called non-target regions. While these advances have improved the safety and tolerability of seizure therapy, a risk of cognitive side effects remains, and none of the currently used procedures individualize the current amplitude for each patient despite knowledge that anatomical variation significantly impacts the strength of the current delivered to the brain. We propose a first-in-human safety and feasibility study of this approach (termed individualized low amplitude seizure therapy , or iLAST). iLAST introduces three areas of improvement over conventional ECT:
with computational electric field modeling on an individual patient basis to examine the
current flow in the brain.
2. an alternative dosing strategy in which the stimulus is titrated in the current amplitude
3. use of high-density EEG electrodes that are weaved into the multi-stimulation electrode
array so that topographical ictal EEG is recorded. As mandated by the US FDA, a first in human (FIH) study is a type of study in which a device for a specific indication is evaluated for the first time in human subjects. We propose a FIH study of iLAST in 10 subjects. If safety and feasibility of iLAST are supported, this could lead to the development of a practical and safer alternative to ECT that could be rapidly disseminated through modification of ECT devices already cleared by the FDA, lowering regulatory barriers and development cost. If the aims are not supported, this would provide further support that development of the magnetic approach to seizure therapy is warranted.
The primary aim of the current protocol is to evaluate the safety and feasibility of iLAST in 10 adults with major depressive episode (unipolar) eligible for ECT. We hypothesize that iLAST will result in superior neurocognitive outcomes than conventional ECT. In addition, we will evaluate the feasibility of alternative methods to individualize the pulse amplitude. The approach to individualizing pulse amplitude is to apply trains of pulses of increasing amplitude until a seizure is induced. To be practical in the clinical setting, the motor threshold (MT) procedure will be completed rapidly to minimize time under anesthesia. To this end, we will evaluate a rapid- estimation motor thresholding algorithm under anesthesia. This will allow us to determine the relationships among measured amplitude-titrated seizure threshold (STa), measured MT, and simulated MT derived from electric field modeling. Our hypothesis is that both measured and simulated MT are correlated with STa, thus providing a clinically useful predictor of current amplitude necessary to perform seizure therapy under the time-constraints of anesthesia.
The study will consist of 10 individuals between 22 and 70 years old, with a major depressive disorder.
This is a within-subject safety and feasibility study that comprises three phases. Phase I includes medication taper (as clinically indicated), and baseline assessments.
In Phase II, patients will receive the 7 ultrabrief pulse width (0.3 ms) seizure therapy conditions. As treatments will be delivered on a 3 per week schedule.
On each experimental condition day, patients will undergo a number of procedures to assess clinical status and safety. Post procedure acute battery assessments will include: a) side effect questionnaire, b) neurocognitive battery, and c) neuroplasticity battery.
In Phase III, patients will be offered routine clinical management consisting of a conventional ECT course (typically 6 12 treatments) based on clinical need. Patients will receive pre- and post- course measures including: clinical rating scales, neurocognitive testing, neuroimaging, and a neuroplasticity battery.
Patients will also receive optional TMS EEG and ictal EEG recording at the 2nd, 8th or final treatment.
Primary Outcome measures: successful seizure induction as measured by topographical EEG and motor manifestations, vital signs, ECG, subjective side effect scale, and adverse events/significant adverse events.
Secondary Outcome measures: Neurocognitive battery known to be sensitive to the cognitive effects of ECT, with alternative versions to avoid practice effects; and, Amplitude-titrated seizure threshold (STa), measured electrical MT, and simulated MT derived from realistic head modeling.
|Treatment||MRI, Multichannel Stimulation Interface, MagPro TMS stimulator and coil, MECTA paired with the 4X1 HD-ECT|
|Clinical Study Identifier||NCT03895658|
|Sponsor||National Institute of Mental Health (NIMH)|
|Last Modified on||29 November 2020|
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