1. Meta-analysis of the efficacy of electroconvulsive therapy in depressive disorders. Door: Mark de Groot 0455253 Marjet van der Vegt 0422053 Michelle Niekoop 0455261

2. Overview What is ECT? – A brief explain What is ECT? – A brief explain PICO PICO Search Strategy Search Strategy Selection Criteria Selection Criteria Bias Bias Calculations & Formulas Calculations & Formulas Forrest Plots & Conclusions Forrest Plots & Conclusions Recommendation Recommendation

3. Introduction to ECT ECT uses 6 to 10 electric pulses which are administered to the brain, these pulses have to break through the depression. ECT uses 6 to 10 electric pulses which are administered to the brain, these pulses have to break through the depression. It is still unknown what the pulses trigger (or triggers) in the brain to break through the depression. It is still unknown what the pulses trigger (or triggers) in the brain to break through the depression.

4. PICO PPatients with depressive disorders PPatients with depressive disorders IElectroconvulsive Therapy IElectroconvulsive Therapy CSimulated ECT and antidepressants CSimulated ECT and antidepressants O(1) Is there a measurable effect of ECT and if there is, (2) is it more efficient than antidepressants? O(1) Is there a measurable effect of ECT and if there is, (2) is it more efficient than antidepressants?

5. Search Strategy PubMed: 1. “Antidepressive Agents” [MeSH] 2. “Electroconvulsive Therapy” [MeSH] 3. “Depressive disorders” 4. #2 AND #3 AND #4

6. Search Strategy Cochrane Library: “Electroconvulsive Therapy” OR ECT “Electroconvulsive Therapy” OR ECT “Electroconvulsive Therapy” AND depression OR “depressive disorders” “Electroconvulsive Therapy” AND depression OR “depressive disorders” ECT OR (Electro* NEAR Therapy) AND depressants ECT OR (Electro* NEAR Therapy) AND depressants #1 AND RCT OR Controlled Trial #1 AND RCT OR Controlled Trial #3 AND RCT #3 AND RCT

7. Search Strategy EMBASE (OVID, CINAHL): “Electroconvulsive Therapy” OR ECT “Electroconvulsive Therapy” OR ECT depression OR “depressive disorders” depression OR “depressive disorders” RCT OR “Random Clinical Trial” OR “Clinical Trial” RCT OR “Random Clinical Trial” OR “Clinical Trial” #1 AND #3 AND Simulated #1 AND #3 AND Simulated #1 AND #2 AND #3 #1 AND #2 AND #3

8. Selection Criteria Criteria RCT? RCT? Well documented? Well documented? No age-restrictions No age-restrictions We made it dichotomous, because most of the publications talked about improvement of life or no improvement We made it dichotomous, because most of the publications talked about improvement of life or no improvementFilter Language – English or Dutch Language – English or Dutch Reachable – AMC library Reachable – AMC library

9. Selection Criteria Excluded Language bias Language bias Presentation bias Presentation bias Observer bias Observer bias

10. Calculations Over the next 2 slides it will be made clear how the calculations have been made by us (and the computer).

11. EffectiveIneffective Real ECT 71421 Sim. ECT 51621 123042 A B C D

12. χ²-test Effecti ve Ineffecti ve Real ECT 71421 Sim. ECT 51621 123042 Effecti ve Ineffecti ve Real ECT 61521 Sim. ECT 61521 123042 Observed Expected 12*21/42

13. Real ECT vs. Simulated ECT

14. Standard Error Ulett 19560,073 Ulett 19560,073 Brill 19590,078 Brill 19590,078 Harris & Robin 19600,177 Harris & Robin 19600,177 Fahy 19630,082 Fahy 19630,082 Freeman 19780,086 Freeman 19780,086 Lambourn & Gill 19780,000 Lambourn & Gill 19780,000 Johnstone 19800,060 Johnstone 19800,060 Brandon 19840,056 Brandon 19840,056 Jagadeesh 19920,076 Jagadeesh 19920,076

15. Pooled Results = 0,889399 = 0,026672 = 248,991

16. Conclusion There is substantial evidence that the Real ECT is more than 1 time [95% CI: 1,28 – 3,18] more efficient (or good response) in treating patients than the simulated ECT. Our research was significant because the overal-interval did not cross the dividing line.

17. Real ECT vs. Antidepressive Agents

18. Standard Error Bruce 19600,040 Bruce 19600,040 Harris & Robin 19600,177 Harris & Robin 19600,177 Kiloh et al. 19600,043 Kiloh et al. 19600,043 Bruce et al. 19600,033 Bruce et al. 19600,033 Robin & Harris 19620,085 Robin & Harris 19620,085 Robin & Harris 19620,072 Robin & Harris 19620,072 Fahy et. al. 19630,083 Fahy et. al. 19630,083 Wilson et al. 19630,000 Wilson et al. 19630,000 Huntchinson 19630,025 Huntchinson 19630,025 Greenblatt et al. 19640,027 Greenblatt et al. 19640,027 Greenblatt & Grosser 19640,038 Greenblatt & Grosser 19640,038 Shepherd 19650,042 Shepherd 19650,042 Med. R. Council 19650,028 Med. R. Council 19650,028 Steiner 19780,150 Steiner 19780,150 Gangadahar 19820,102 Gangadahar 19820,102 Dinan & Barry 19890,081 Dinan & Barry 19890,081 Folkerts et. al. 19970,072 Folkerts et. al. 19970,072 Janakirmaiah 20000,046 Janakirmaiah 20000,046

19. Pooled Results = 1,395413 = 0,010484 = 1761,059

20. Conclusion There is substantial evidence that ECT is more than 2,5 times [95% CI: 2,60 – 4,68] more efficient (or good response) in treating patients than the antidepressive agents. Our research was significant because the overal-interval did not cross the dividing line.

21. Recommendation Although our research is positive about the ECT, there is not much known about the effects of ECT. That area has to be researched and there are still side-effects which we have to take care of. ECT can be useful in treatment of depressive disorders, but keep the side-effects in mind.