Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE)

Stuck in a rut: rethinking depression and its treatment

The current definition of major depressive disorder (MDD) emerged from efforts to create reliable diagnostic criteria for clinical and research use. However, despite decades of research, the neurobiology of MDD is largely unknown, and treatments are no more effective today than they were 50-70 years ago. Here, we propose that the current conception of depression is misguiding basic and clinical research. Redefinition is necessary and could include a focus on a more narrowly defined set of core symptoms. However, we conclude that depression is better defined as the tendency to enter into, and inability to disengage from, a negative mood state rather than the mood state per se. We also discuss the implications of this revised definition for future clinical and basic research.

Advances in the Management of Treatment-Resistant Depression

Treatment-resistant depression (TRD) is a prevalent, disabling, and costly condition affecting 1%-4% of the U.S.

POPULATION

Current approaches to managing TRD include medication augmentation (with lithium, thyroid hormone, buspirone, atypical antipsychotics, or various antidepressant medications), psychotherapy, and ECT. Advances in understanding the neurobiology of mood regulation and depression have led to a number of new potential approaches to managing TRD, including medications with novel mechanisms of action and focal brain stimulation techniques. This review will define and discuss the epidemiology of TRD, review the current approaches to its management, and then provide an overview of several developing interventions.

A review of continuation electroconvulsive therapy: application, safety, and efficacy

Electroconvulsive therapy (ECT) is a neurostimulation therapeutic intervention that is highly effective and frequently used to treat certain psychiatric conditions, particularly major depressive disorder. Despite its high efficacy, a major limitation of ECT is the significant rate at which patients relapse after treatment. Providing additional ECT treatments after completion of a short-term course of ECT, referred to as continuation ECT (C-ECT), is a strategy used to reduce the risk of relapse. Specifically, C-ECT involves the administration of additional ECT treatments during the 6-month period after remission. This article summarizes the available literature regarding C-ECT including indication for use, patient selection, treatment guidelines/parameters, and safety. The efficacy of C-ECT is also discussed, with a focus on major depressive disorder and schizophrenia. On the basis of the current literature, indications for use and patient selection for C-ECT are predominately similar to those for a short-term ECT course. The treatment guidelines/parameters for C-ECT are recommended to be consistent with the parameters used to achieve remission, with the exception of greater intertreatment intervals during C-ECT. Although adverse cognitive effects can occur during C-ECT, the risk and severity of cognitive impairment are generally low, possibly because of the greater intertreatment intervals. Most research supports the use of C-ECT to prolong remission; however, methodologic limitations mitigate firm conclusions and generalizability of these findings. Nonetheless, the available evidence supports the use of C-ECT as a safe and effective method in relapse prevention.

Electrode placement in electroconvulsive therapy (ECT): A review of the literature

Electrode placement in electroconvulsive therapy affects both the efficacy and adverse cognitive effect profile of the treatment. For many years, 2 placements, bitemporal (also referred to as "bifrontotemporal" or simply "bilateral") and right unilateral, were the principal placements in widespread clinical use. More recently, bifrontal placement has joined their ranks as a commonly used placement. In this article, we review the evidence base for the efficacy and safety of each of these electrode placements for the indication of depression, describe another novel placement, and then draw conclusions from this available evidence base, pointing out areas in need of further study.

Adjunctive psychotropic medications during electroconvulsive therapy in the treatment of depression, mania, and schizophrenia

Current guidelines regarding concomitant antidepressants during electroconvulsive therapy (ECT) are inconsistent. Although the American Psychiatric Association Task Force on ECT discouraged combination antidepressant treatment, owing to the minimal evidence for enhanced efficacy and concern about increased adverse effects, combination treatment is recommended and considered routine for many practitioners in the United States and other parts of the world. Considering the increasing levels of treatment resistance among patients referred for ECT and the high relapse rate after acute ECT, the role of concomitant antidepressant pharmacotherapy during ECT should be reevaluated. More research, however, is needed to explore the impact of administering specific antidepressants during acute and maintenance ECT (M-ECT), on antidepressant efficacy and cognitive adverse effects. This will require appropriately controlled studies of ECT medication combinations that include attention to a range of cognitive function measures and clinical response. In addition, the role of combination ECT and psychotropic medication in the treatment of mania and schizophrenia continues to receive attention, particularly in those patients who have shown inadequate responses to psychotropic medication alone. Although there is insufficient evidence to support the routine addition of antipsychotic medications to ECT during the treatment of acute mania, the literature suggests that it is unnecessary to discontinue antipsychotic medication when ECT is added to the treatment of a manic patient that has been unresponsive to pharmacological treatment. Despite the lack of well-controlled studies, the existing literature suggests that combination ECT and antipsychotic treatment is a useful option for patients with schizophrenia who are unresponsive to pharmacological interventions alone, and its adverse effect profile does not seem different from that seen with ECT alone.

Electroconvulsive therapy is equally effective in unipolar and bipolar depression

OBJECTIVE

To determine the relative efficacy of electroconvulsive therapy (ECT) in the treatment of bipolar (BP) and unipolar (UP) depressive illness and clarify its role in BP depression.

METHOD

Patients referred for ECT with both UP and BP depressions. [classified by Structured Clinical Interview for DSM (SCID-I) criteria for history of mania] were included in a multi-site collaborative, double-masked, randomized controlled trial of three electrode placements - right unilateral, bifrontal or bitemporal - in a permutated block randomization scheme.

RESULTS

Of 220 patients, 170 patients (77.3%) were classified as UP and 50 (22.7%) as BP depression in the intent-to-treat sample. The remission and response rates and numbers of ECT for both groups were equivalent.

CONCLUSION

Both UP and BP depressions remit with ECT. Polarity is not a factor in the response rate. In this sample ECT did not precipitate mania in depressed patients. Treatment algorithms for UP and BP depression warrant re-evaluation.

Combined catecholamine and indoleamine depletion following response to ECT

The mechanism of action of electroconvulsive therapy (ECT) in treating major depression is unknown. We studied two candidate mechanisms through inhibiting simultaneously the synthesis of noradrenaline and serotonin in patients immediately after successful treatment with ECT using a randomised, placebo-controlled, double-blind crossover design. There were no significant changes in depression scores under any experimental conditions, or between the amine-depleted and placebo groups despite reductions of 61% in serum homovanillic acid, 47% in 3-methoxy-4-hydroxyenylethyleneglycol, and 89% in serum tryptophan. Catecholamine and serotonin availability may not be necessary for maintaining the initial antidepressant response to ECT.

Combination of pharmacotherapy with electroconvulsive therapy in prevention of depressive relapse: a pilot controlled trial

OBJECTIVE

Relapse rates after electroconvulsive therapy (ECT) remain high with standard treatments. We aimed to test the efficacy of an early administered continuation pharmacotherapy (c-pharm early) strategy in prevention of post-ECT relapse.

METHOD

A 20-week, randomized, double-blind, placebo-controlled trial. Patients aged 18 to 65 years diagnosed with Diagnostic and Statistical Manual of Mental Disorders major depressive disorder, with or without psychotic features, with initial Montgomery-Asberg Depression Rating Scale scores higher than 22, underwent 8 bilateral ECT sessions (2 per week). Randomization to c-pharm early, c-pharm late, and placebo groups in 2:2:1, respectively, was performed at the completion of the fourth ECT session. After randomization, subjects in the c-pharm early group were given sertraline at 150 mg/d. Subjects in the c-pharm late group were first given placebo, which was substituted with sertraline at 150 mg/d at the completion of the eight ECT. Relapse was defined as a Montgomery-Asberg Depression Rating Scale score of 16 or higher.

RESULTS

Seventy-three percent of the patients responded to the given treatment. The relapse rates were 12.5% in the c-pharm early group, 28% in the c-pharm late group, and 67% in the placebo group (P = 0.09). The c-pharm early strategy resulted in significantly lower relapse rates and longer well time compared with the placebo (P = 0.04). When the trend with the initiation of the c-pharm intervention was investigated in the 3 groups with equally spaced trend weights, the time of initiation was found to have a significant effect on the probability of the remaining well (P = 0.03).

CONCLUSIONS

Comparative efficacy of c-pharm early and late strategies in providing improved protection against post-ECT relapse of major depressive disorder needs to be further explored.

Maintenance electroconvulsive therapy in autistic catatonia: a case series review

The usage of electroconvulsive therapy for the acute resolution of catatonia in autistic children and adults is a novel area that has received increased attention over the past few years. Reported length of the acute ECT course varies among these patients, and there is no current literature on maintenance ECT in autism. The maintenance ECT courses of three patients with autism who developed catatonia are presented. Clinical, research, legal, and administrative implications for ECT treatment in this special population are discussed.

Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial

BACKGROUND

Electroconvulsive therapy (ECT) is an effective treatment for major depression. Optimising efficacy and minimising cognitive impairment are goals of ongoing technical refinements.

AIMS

To compare the efficacy and cognitive effects of a novel electrode placement, bifrontal, with two standard electrode placements, bitemporal and right unilateral in ECT.

METHOD

This multicentre randomised, double-blind, controlled trial (NCT00069407) was carried out from 2001 to 2006. A total of 230 individuals with major depression, bipolar and unipolar, were randomly assigned to one of three electrode placements during a course of ECT: bifrontal at one and a half times seizure threshold, bitemporal at one and a half times seizure threshold and right unilateral at six times seizure threshold.

RESULTS

All three electrode placements resulted in both clinically and statistically significant antidepressant outcomes. Remission rates were 55% (95% CI 43-66%) with right unilateral, 61% with bifrontal (95% CI 50-71%) and 64% (95% CI 53-75%) with bitemporal. Bitemporal resulted in a more rapid decline in symptom ratings over the early course of treatment. Cognitive data revealed few differences between the electrode placements on a variety of neuropsychological instruments.

CONCLUSIONS

Each electrode placement is a very effective antidepressant treatment when given with appropriate electrical dosing. Bitemporal leads to more rapid symptom reduction and should be considered the preferred placement for urgent clinical situations. The cognitive profile of bifrontal is not substantially different from that of bitemporal.

Riluzole for relapse prevention following intravenous ketamine in treatment-resistant depression: a pilot randomized, placebo-controlled continuation trial

The N-methyl-D-aspartate (NMDA) glutamate receptor antagonist ketamine may have rapid, albeit transient, antidepressant properties. This study in patients with treatment-resistant major depression (TRD) aimed to (1) replicate the acute efficacy of single-dose intravenous (i.v.) ketamine; (2) test the efficacy of the glutamate-modulating agent riluzole in preventing post-ketamine relapse; and (3) examine whether pretreatment with lamotrigine would attenuate ketamine's psychotomimetic effects and enhance its antidepressant activity. Twenty-six medication-free patients received open-label i.v. ketamine (0.5 mg/kg over 40 min). Two hours prior to infusion, patients were randomized to lamotrigine (300 mg) or placebo. Seventeen patients (65%) met response criterion (50% reduction from baseline on the Montgomery-Asberg Depression Rating Scale) 24 h following ketamine. Lamotrigine failed to attenuate the mild, transient side-effects associated with ketamine and did not enhance its antidepressant effects. Fourteen patients (54%) met response criterion 72 h following ketamine and proceeded to participate in a 32-d, randomized, double-blind, placebo-controlled, flexible-dose continuation trial of riluzole (100-200 mg/d). The main outcome measure was time-to-relapse. An interim analysis found no significant differences in time-to-relapse between riluzole and placebo groups [log-rank chi(2) = 0.17, d.f. = 1, p = 0.68], with 80% of patients relapsing on riluzole vs. 50% on placebo. The trial was thus stopped for futility. This pilot study showed that a sub-anaesthetic dose of i.v. ketamine is well-tolerated in TRD, and may have rapid and sustained antidepressant properties. Riluzole did not prevent relapse in the first month following ketamine. Further investigation of relapse prevention strategies post-ketamine is necessary.

Safety and efficacy of repeated-dose intravenous ketamine for treatment-resistant depression

BACKGROUND

A single subanesthetic (intravenous) IV dose of ketamine might have rapid but transient antidepressant effects in patients with treatment-resistant depression (TRD). Here we tested the tolerability, safety, and efficacy of repeated-dose open-label IV ketamine (six infusions over 12 days) in 10 medication-free symptomatic patients with TRD who had previously shown a meaningful antidepressant response to a single dose.

METHODS

On day 1, patients received a 40-min IV infusion of ketamine (.5 mg/kg) in an inpatient setting with continuous vital-sign monitoring. Psychotomimetic effects and adverse events were recorded repeatedly. The primary efficacy measure was change from baseline in the Montgomery-Asberg Depression Rating Scale (MADRS) score. If patients showed a > or =50% reduction in MADRS scores on day 2, they received five additional infusions on an outpatient basis (days 3, 5, 8, 10, and 12). Follow-up visits were conducted twice-weekly for > or =4 weeks or until relapse.

RESULTS

Ketamine elicited minimal positive psychotic symptoms. Three patients experienced significant but transient dissociative symptoms. Side effects during and after each ketamine infusion were generally mild. The response criterion was met by nine patients after the first infusion as well as after the sixth infusion. The mean (SD) reduction in MADRS scores after the sixth infusion was 85% (12%). Postketamine, eight of nine patients relapsed, on average, 19 days after the sixth infusion (range 6 days-45 days). One patient remained antidepressant-free with minimal depressive symptoms for >3 months.

CONCLUSIONS

These pilot findings suggest feasibility of repeated-dose IV ketamine for the acute treatment of TRD.

Relative ineffectiveness of ultrabrief right unilateral versus bilateral electroconvulsive therapy in depression

OBJECTIVE

Bilateral (BL) electrode placement delivered at 2.5 times the initial seizure threshold (ST; 2.5 x ST) is the gold standard method for seizure delivery during electroconvulsive therapy (ECT). However, there is a growing interest in using a high dose (6 x ST) with ultrabrief right unilateral (UB-RUL) electrode placement to reduce the incidence of possible short-term memory problems associated with BL ECT. Although studies have found UB-RUL ECT to have similar effectiveness to BL ECT, the objective of this study was to determine potential differences in efficiency (ie, the number of treatments needed to reach remission).

METHODS

Electroconvulsive therapeutic data for 56 patients with depression treated during 2006 and 2007 were analyzed via retrospective chart review. A total of 26 patients were started on UB-RUL ECT, whereas 30 patients were started on brief pulse BL ECT.

RESULTS

The patients started on high-dose UB-RUL ECT required significantly more treatments than the patients started on BL ECT (9.4 [3.3] vs 7.7 [2.8] treatments). Of the 26 patients started on UB-RUL ECT, 12 (46%) experienced a lack of effectiveness and/or insufficient seizure induction and were thus switched to BL ECT; the 8 patients switched because of lack of effectiveness received a mean (SD) of 12.2 (2.9) treatments, whereas the 4 patients switched because of insufficient seizure induction received a mean (SD) of 11.3 (3.6) treatments.

CONCLUSIONS

These findings add to an emerging story of reduced efficiency of UB-RUL versus BL electrode placement for an index course of ECT for the treatment of depression.

Seizure threshold in a large sample: implications for stimulus dosing strategies in bilateral electroconvulsive therapy: a report from CORE

OBJECTIVE

We sought to examine the relationship of seizure threshold (ST) to age and other demographic characteristics in a large sample where ST was determined by the dose titration (DT) method. We also compared the resulting stimulation levels to estimates predicted by an age-based formula, the half-age (HA) method.

METHODS

In a multicenter prospective study, patients received a standardized course of bilateral electroconvulsive therapy for major depression using a brief pulse device. The ST was determined at the first treatment using a fixed algorithm of stimulations. Subsequent seizures were induced at a level 50% higher than the empirically determined ST. We only included data from subjects receiving methohexital anesthesia. We correlated ST with demographic and clinical characteristics of the sample. The actual dosing levels at the second treatment were compared with estimates based on HA.

RESULTS

Of the original 531 subjects, 402 met criteria for the current analysis. The ST was positively correlated with age. Male patients had slightly higher ST than female patients. Neither race, severity of illness, psychosis, nor use of psychotropic medications affected ST. Little variability in titrated ST was observed among our patients. An ST of 40 ("percent of charge") or lower was found in 97.5% of patients, with either 20 or 40 in 80% of patients. Ninety-six percent of the patients were treated at the 3 levels of 15%, 30%, or 60%. Estimated HA stimulus levels offered a wider range of choices compared with this particular algorithm used for ST determination at an average level of 18% above the determined ST.

CONCLUSIONS

Seizure threshold correlates strongly with age, whereas there is a weaker relation between ST and sex. There was little individual variation of ST determined by the DT method among subjects, possibly because of the wide spacing between steps of this particular titration algorithm. Half-age estimates were 18% above the empirically determined ST. This suggests that the use of the HA estimates at the first treatment may result in fewer stimulations compared with the DT method.

Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. IV. Neurostimulation therapies

BACKGROUND

In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. There is renewed interest in refined approaches to brain stimulation, particularly for treatment resistant major depressive disorder (MDD).

METHODS

The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support. This section on "Neurostimulation Therapies" is one of 5 guidelines articles.

RESULTS

Among the four forms of neurostimulation reviewed in this section, electroconvulsive therapy (ECT) has the most extensive evidence, spanning seven decades. Repetitive transcranial magnetic (rTMS) and vagus nerve stimulation (VNS) have been approved to treat depressed adults in both Canada and the United States with a much smaller evidence base. There is also emerging evidence that deep brain stimulation (DBS) is effective for otherwise treatment resistant depression, but this is an investigational approach in 2009.

LIMITATIONS

Compared to other modalities for the treatment of MDD, the data based is limited by the relatively small numbers of randomized controlled trials (RCTs) and small sample sizes.

CONCLUSIONS

There is most evidence to support ECT as a first-line treatment under specific circumstances and rTMS as a second-line treatment. Evidence to support VNS is less robust and DBS remains an investigational treatment.

Electroconvulsive therapy: Part II: a biopsychosocial perspective

The myths surrounding electroconvulsive therapy (ECT) and the misconceptions held by the general public, clinicians, and patients have interfered with acceptance of this treatment throughout its history. Misunderstandings surrounding ECT, and its consequent stigmatization, are reviewed, including negative depictions of ECT in film, print media, and on the Internet. Clinicians involved in the delivery of ECT benefit from gaining an understanding of how ECT may be perceived by patients and other mental health professionals; they can play a vital role in educating patients and helping ensure the delivery of a successful course of ECT. Guidance is provided for clinicians on how to support patients and families through the ECT process using a model team approach. Anxiety reduction, meeting individual needs, patient and family psychoeducation, assessment of psychosocial supports, and discharge planning are discussed.

Sense of coherence in patients treated for depression with ECT

OBJECTIVE

The purpose of the study was to investigate whether the Antonovsky Sense of Coherence test administered before and after electroconvulsive treatment (ECT) can contribute more information pertinent to outcome than a test of depression.

METHOD

Twenty patients with a severe unipolar or bipolar depression underwent a series of unipolar ECT under standard conditions. As part of the routine of the department, the patients filled in, before and after ECT, the following questionnaires: Beck Depression Inventory (Beck), 20-item version and Antonovsky Sense of Coherence test (SOC), 13-item version. Mean age was 40.3, somewhat less for women.

RESULTS

A reduction was obtained from 35 to 17 in total score on Beck, i.e., to mild depression. The SOC value increased to the normal range from a mean of 2.5 to 3.2, indicating a better manageability, comprehensibility and meaningfulness in life. Four patients had an invalidity pension. Ten of the 16 remaining patients attained work after ECT, and scored better than those not starting to work on both tests, SOC > Beck. A low SOC value may indicate increased mortality risk.

CONCLUSIONS

Patients who are favorably treated with ECT against any depression, but who do not show a considerable improvement in SOC, would need special follow-up on factors not directly related to mental illness to reduce relapse and mortality risk.

Antidepressant response to electroconvulsive therapy is sustained after catecholamine depletion

Although the antidepressant mechanism of ECT is unknown, there are data to support noradrenergic involvement. Patients who had been recently successfully treated with ECT for major depression were studied in a randomized double-blind cross-over design comparing catecholamine depletion using alpha-methyl-para-tyrosine to a placebo procedure. Mean MADRS scores at baseline (4.2 SD 2.7) and following depletion (4.6 SD 1.1) were similar, despite a 57.7% decrease in serum homovanillic acid (HVA) and a 61.5% decrease in 3-methoxy-4-hydroxyenylethyleneglycol (MHPG). These data suggest that catecholamine availability may not be necessary for acutely maintaining an antidepressant response to ECT.

Citalopram for continuation therapy after repetitive transcranial magnetic stimulation in vascular depression

OBJECTIVES

The authors previously reported that repetitive transcranial magnetic stimulation (rTMS) produced a response rate of 39.4% among 62 patients with treatment resistant vascular depression. This study was undertaken to assess the outcome of continuation therapy to prevent relapse among these patients during 9 weeks after completion of rTMS.

DESIGN

Patients were randomly assigned to 18,000 pulses of rTMS given over 3 weeks or sham treatment using double blind methods. After rTMS, all patients were given 20 mg/day of citalopram for 9 weeks and reevaluated at 3, 6, and 9 weeks.

SETTING

Outpatient continuation treatment trial.

PARTICIPANTS

Patients with vascular depression (N = 62), as determined by magnetic resonance imaging hyperintensities and three or more clinical risk factors for vascular disease without other major medical illness, were recruited. They had onset of major depression after age 50 and failed at least one trial of antidepressants.

INTERVENTION

After rTMS or sham treatment, all treatment responders were given citalopram for 9 weeks.

RESULTS

Among the 33 patients who were given rTMS, 13 responded (i.e., >50% decline in Hamilton Depression Scale score). Of these 13, all completed the 9 weeks of continuation treatment. There were nine patients who continued to be responders and four who had a relapse of depression.

CONCLUSION

More effective methods are needed to treat elderly patients with treatment resistant vascular depression and to prevent relapse among treatment responders.

Emerging targets for antidepressant therapies

Despite adequate antidepressant monotherapy, the majority of depressed patients do not achieve remission. Even optimal and aggressive therapy leads to a substantial number of patients who show minimal and often only transient improvement. In order to address this substantial problem of treatment-resistant depression, a number of novel targets for antidepressant therapy have emerged as a consequence of major advances in the neurobiology of depression. Three major approaches to uncover novel therapeutic interventions are: first, optimizing the modulation of monoaminergic neurotransmission; second, developing medications that act upon neurotransmitter systems other than monoaminergic circuits; and third, using focal brain stimulation to directly modulate neuronal activity. We review the most recent data on novel therapeutic compounds and their antidepressant potential. These include triple monoamine reuptake inhibitors, atypical antipsychotic augmentation, and dopamine receptor agonists. Compounds affecting extra-monoamine neurotransmitter systems include CRF(1) receptor antagonists, glucocorticoid receptor antagonists, substance P receptor antagonists, NMDA receptor antagonists, nemifitide, omega-3 fatty acids, and melatonin receptor agonists. Focal brain stimulation therapies include vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS), magnetic seizure therapy (MST), transcranial direct current stimulation (tDCS), and deep brain stimulation (DBS).

Antidepressant electroconvulsive therapy: mechanism of action, recent advances and limitations

A considerable number of depressive patients do not respond to or remit during pharmacotherapeutical or psychotherapeutical interventions resulting in an increasing interest in non-pharmacological strategies to treat affective disorders. Electroconvulsive therapy (ECT) dates back to the beginning of modern biologic psychiatry and ongoing research has successfully improved efficacy in addition to safety while reducing side effects. Double-blind, randomized, controlled trials have shown powerful interactions between electrode placement (right unilateral, bifrontal, bitemporal) and dosage (relative to seizure threshold) in the efficacy and side effects of ECT. This review aims to summarize current research data on the mechanism of action, efficacy, and recent advances in ECT technique.

Clinical issues in considering vagus nerve stimulation for treatment-resistant depression

This review briefly discusses the clinical and basic science rationale for vagus nerve stimulation (VNS) in treatment-resistant depression (TRD). As the number of treatment failures for depression increases, the likelihood of achieving remission during acute treatment decreases, and the risk of relapse increases with the number of treatment failures. Two open trials of adjunctive VNS for TRD showed positive acute results and a growing benefit over time. The results of the acute randomized controlled trial were not significant for the primary outcome (response by HRSD-24), but the secondary measure (IDS-SR-30) was significant for VNS. A 12-month nonrandomized comparative analysis of patients receiving adjunctive VNS with TRD patients receiving treatment as usual showed significant results favoring VNS. Post hoc analyses found that this difference was not accounted for baseline differences nor by intercurrent treatment. While VNS is well tolerated, the optimal dosing strategies have not been determined nor have clinically useful predictors of who will respond to the treatment. Given the profound effects of TRD upon the daily lives of patients and that a substantial number of VNS patients receive benefit, VNS is a useful option for managing patients with TRD.

Eletroconvulsoterapia na depressão maior: aspectos atuais

OBJETIVO: A eficácia da eletroconvulsoterapia em tratar sintomas depressivos está estabelecida por meio de inúmeros estudos desenvolvidos durante as últimas décadas. A eletroconvulsoterapia é o tratamento biológico mais efetivo para depressão atualmente disponível. O objetivo deste estudo foi demonstrar o papel da eletroconvulsoterapia no tratamento da depressão e destacar aspectos atuais relativos à sua prática. MÉTODO: Foram revisados na literatura estudos de eficácia, remissão de sintomas, fatores preditores de resposta, assim como aspectos atuais acerca da qualidade de vida, percepção dos pacientes, mecanismo de ação, técnica e prejuízo cognitivos. RESULTADOS: Os principais achados desta revisão foram: 1) a eletroconvulsoterapia é mais efetiva do que qualquer medicação antidepressiva; 2) a remissão da depressão com a eletroconvulsoterapia varia, em geral, de 50 a 80%; 3) Ainda é controverso o efeito da eletroconvulsoterapia nos níveis de fator neurotrófico derivado do cérebro (acho que aqui pode colocar entre parenteses o "BNDF"); 4) a eletroconvulsoterapia tem efeito positivo na melhora da qualidade de vida; 5) os pacientes submetidos à eletroconvulsoterapia, em geral, têm uma percepção positiva do tratamento. CONCLUSÃO: A eletroconvulsoterapia permanece sendo um tratamento altamente eficaz em pacientes com depressão resistente. Com o avanço da sua técnica, a eletroconvulsoterapia tornou-se um procedimento ainda mais seguro e útil tanto para a fase aguda, quanto para a prevenção de novos episódios depressivos.

Clinical practice recommendations for depression

OBJECTIVE

To provide clinically relevant evidence-based recommendations for the management of depression in adults that are informative, easy to assimilate and facilitate clinical decision making.

METHOD

A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. The recommendations then underwent consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives.

RESULTS

The clinical practice recommendations for depression (Depression CPR) summarize evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative.

CONCLUSION

These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of depression. Further, the novel style and practical approach should promote uptake and implementation.

Targeted electrode-based modulation of neural circuits for depression

During the last 20 years of neuroscience research, we have witnessed a fundamental shift in the conceptualization of psychiatric disorders, with the dominant psychological and neurochemical theories of the past now complemented by a growing emphasis on developmental, genetic, molecular, and brain circuit models. Facilitating this evolving paradigm shift has been the growing contribution of functional neuroimaging, which provides a versatile platform to characterize brain circuit dysfunction underlying specific syndromes as well as changes associated with their successful treatment. Discussed here are converging imaging findings that established a rationale for testing a targeted neuromodulation strategy, deep brain stimulation, for treatment-resistant major depression.

Treatment strategies to improve and sustain remission in major depressive disorder

Major depressive disorder (MDD) is an often chronic, recurrent illness affecting large numbers of the general population. In recent years, the goal of treatment for MDD has moved from mere symptomatic response to that of full remission (i.e., minimal/no residual symptoms). The recent Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial showed that even with systematic measurement-based treatment, approximately one third of patients reach full remission after one treatment trial, with only two thirds reaching remission after four treatment trials. Treatment-resistant depression (TRD) is therefore a common problem in the treatment of MDD, with 60% to 70% of all patients meeting the criteria for TRD. Given the huge burden of major depressive illness, the low rate of full recovery remains suboptimal. The following article reports on some current treatment strategies available to improve rates of, and to sustain, remission in MDD.

Post- ECT Pharmacotherapy: An Update

Electroconvulsive therapy (ECT) is a very effective treatment in severe psychiatric disorders. One of the main drawbacks of ECT is the high and early relapse rate in the absence of post- ECT treatment. After a successful ECT- course, pre- ECT pharmacotherapy is often continued. There is, however, no evidence that proves this strategy effective. The research on post- ECT treatments is limited, but promising. The available studies show that relapse rates can be decreased from more than 80% to 40% or less using either imipramine (1), the combination of lithium and nortriptyline (2) or continuation- ECT (3). The question whether or not starting antidepressants during the course of ECT ca further decrease relapse rates remains unanswered. Preliminary data show that starting antidepressants medication during the ECT course has no impact on post- ECT relapse. There is an urgent need for further research on treatment strategies to decrease the unacceptable high relapse rates after recovery from ECT.

Neurostimulatory therapeutics in management of treatment-resistant depression with focus on deep brain stimulation

Treatment-resistant depression continues to pose a major medical challenge, as up to one-third of patients with major depressive disorder fail to have an adequate response to standard pharmacotherapies. An improved understanding of the complex circuitry underlying depressive disorders has fostered an explosion in the development of new, nonpharmacological approaches. Each of these treatments seeks to restore normal brain activity via electrical or magnetic stimulation. In this article, the authors discuss the ongoing evolution of neurostimulatory treatments for treatment-resistant depression, reviewing the methods, efficacy, and current research on electroconvulsive therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy, focal electrically administered stimulated seizure therapy, transcranial direct current stimulation, chronic epidural cortical stimulation, and vagus nerve stimulation. Special attention is given to deep brain stimulation, the most focally targeted approach. The history, purported mechanisms of action, and current research are outlined in detail. Although deep brain stimulation is the most invasive of the neurostimulatory treatments developed to date, it may hold significant promise in alleviating symptoms and improving the quality of life for patients with the most severe and disabling mood disorders.

Novel targets for antidepressant therapies

Most depressed patients fail to achieve remission despite adequate antidepressant monotherapy, and a substantial minority show minimal improvement despite optimal and aggressive therapy. However, major advances have taken place in elucidating the neurobiology of depression, and several novel targets for antidepressant therapy have emerged. Three primary approaches are currently being taken: 1) optimizing the pharmacologic modulation of monoaminergic neurotransmission, 2) developing medications that target neurotransmitter systems other than the monoamines, and 3) directly modulating neuronal activity via focal brain stimulation. We review novel therapeutic targets for developing improved antidepressant therapies, including triple monoamine reuptake inhibitors, atypical antipsychotic augmentation, dopamine receptor agonists, corticotropin-releasing factor-1 receptor antagonists, glucocorticoid receptor antagonists, substance P receptor antagonists, N-methyl-D-aspartate receptor antagonists, nemifitide, omega-3 fatty acids, and melatonin receptor agonists. Developments in therapeutic focal brain stimulation include vagus nerve stimulation, transcranial magnetic stimulation, magnetic seizure therapy, transcranial direct current stimulation, and deep brain stimulation.

Efficacy of maintenance electroconvulsive therapy in recurrent depression: a naturalistic study

BACKGROUND AND OBJECTIVE

The use of maintenance electroconvulsive therapy (mECT) in contemporary psychiatric practice is controversial. In the United Kingdom, the National Institute for Health and Clinical Excellence has recommended that mECT should not be used, although evidence underpinning this decision is lacking. Undertaking a randomized evaluation of this treatment would now be very difficult in the United Kingdom. The main aim of this study is to evaluate the efficacy of mECT in reducing recurrence in depression.

METHOD

A retrospective analysis of 19 patients who had responded positively to an index and continuation course of ECT and then proceeded to receive mECT. We compared the number of hospital admissions and duration of hospital stay over 3 time periods: 2 years before ECT, during mECT, and up to 4 years after cessation of mECT. To account for secular trends in service use, we also compared the admission rates of this group with a matched sample who received successful index ECT followed by other maintenance therapies (comparison group).

RESULTS

Participants received an average of 37 applications of mECT over a median period of 26 months. Inpatient hospital stay and rate of admissions to an acute psychiatric unit fell significantly during the period of mECT compared with the rates before the initiation of mECT. This reduction in bed use was maintained after termination of mECT. No reduction of service use was observed in the comparison group.

CONCLUSIONS

The findings suggest that mECT may have a role in reducing the rate and duration of hospital stay of patients with major depressive disorder.

Toward individualized post-electroconvulsive therapy care: piloting the Symptom-Titrated, Algorithm-Based Longitudinal ECT (STABLE) intervention

OBJECTIVES

Effective strategies to prolong remission after electroconvulsive therapy (ECT) are urgently needed. Fixed schedules for continuation ECT (C-ECT) cannot adapt to early signs of impending relapse. Symptom-Titrated, Algorithm-Based Longitudinal ECT (STABLE) is proposed as a novel patient-focused approach to individualize the ECT schedule. In STABLE, the ECT schedule adapts to symptom fluctuations to prevent overtreatment of those who do not need it and to recapture response in those who might have otherwise relapsed with a rigid dosing schedule. Here we back-test STABLE to optimize the algorithm for subsequent testing in a prospective trial.

METHODS

Three variations of the STABLE algorithm, differing in cutoff points to trigger or withhold additional ECT, were back-tested in a data set of 89 patients randomized to the C-ECT arm in the CORE (Consortium for Research on ECT) Study comparing C-ECT with combination pharmacotherapy.

RESULTS

The selected algorithm identified 100% of patients who ultimately relapsed as requiring additional ECT at an average of 2.2 weeks before relapse, while exposing 20% of sustained remitters to additional ECT. Other variations either failed to capture impending relapse or exposed an unacceptably large percentage of patients to potentially unnecessary ECT.

CONCLUSIONS

This patient-focused approach to relapse prevention is an attempt to provide the first operationalized guidance to the field regarding how to conduct C-ECT. The effectiveness of this approach should be tested in a randomized controlled trial.

Individualized continuation electroconvulsive therapy and medication as a bridge to relapse prevention after an index course of electroconvulsive therapy in severe mood disorders: a naturalistic 3-year cohort study

Electroconvulsive therapy (ECT) is recognized as an effective acute treatment for mood disorders but is associated with high risk of relapse. To minimize this risk, we introduced as a routine individually tapered continuation ECT with concomitant medication (C-ECT + Med) after an index series in January 2000. In August 2002, a chart review of all patients (n = 41) who had received C-ECT + Med for more than 4 months was carried out. Sixteen patients also participated in an extensive interview. Mean duration of administered C-ECT at follow-up was 1 year, but for most patients (63%), C-ECT had been terminated. For 49% of patients, adjustments between ECT sessions had been made due to early signs of relapse. Two weeks was the most common interval between sessions for patients with ongoing C-ECT. The frequency of lithium-treated patients had increased from 12% before index to 41% during C-ECT. However, the rated response to the drug varied. Need for hospital care 3 years before and after the initiation of C-ECT + Med was compared in a second evaluation of the cohort. The number of patients hospitalized, number of admissions, and total days in hospital were all significantly reduced. Hospital days were reduced by 76% (P < 0.001). Three patients with previously cumulative years in hospital are described as case vignettes after 6 years with no or minimal need for further hospitalization. This study supports previous findings that individually tapered C-ECT + Med can maintain initial response to ECT and serve as a bridge to long-term relapse prevention.

The effects of ECT on cognitive functioning in the elderly: a review

BACKGROUND

Electroconvulsive therapy (ECT) as a single course or in maintenance form (M-ECT) is an effective treatment in depressed elderly. However, ECT may have adverse effects on cognition.

OBJECTIVE

To review all studies from 1980-2006 on ECT and cognition in the elderly with a minimum age of 55 years or a mean age of 55 years, and with valid measurements of cognition before and after ECT.

RESULTS

Nine out of the 15 eligible studies were focused exclusively on the elderly. Three studies reported verbal learning- and recall problems post ECT, while three studies found positive effects of ECT on memory, speed of processing and concentration. Global cognitive functioning in patients with cognitive impairment improved in all studies. At follow up, most studies reported improvement of cognitive functions. Learning verbal information and executive functioning were impaired in M-ECT patients whereas global cognition remained stable after M-ECT over a year.

CONCLUSIONS

To date research of ECT on cognitive functioning in the elderly is very limited. Small sample size, lack of controls, use of a single screening instrument and a short follow up period may explain the conflicting results. Given the clinical importance, more extensive research on cognition in elderly treated with ECT is urgently needed.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines

A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.

Change in seizure threshold during electroconvulsive therapy

The seizure threshold (ST) is a measure of the minimum electrical energy necessary to induce a grand mal seizure. Dose titration of the ST has been suggested to optimize stimulus dosing in electroconvulsive therapy (ECT). The change in ST with remission is examined in a large sample of unipolar depressed patients.

METHODS

In a study of continuation treatments after successful ECT, the ST was determined at the first treatment and again 1 week after remission using a conventional ST measurement protocol. Patients were treated with bilateral electrode placement at 150% above the measured ST.

RESULTS

In 80 subjects, the ST measured the same in 70%, increased in 21%, and decreased in 9% at remission.

CONCLUSIONS

In a study of bilateral ECT, the ST did not rise conclusively with remission.

Outcome of electroconvulsive therapy by race in the Consortium for Research on Electroconvulsive Therapy multisite study

OBJECTIVE

The authors examine the differences in outcome between black and white patients receiving electroconvulsive therapy (ECT) as a part of the Consortium for Research on Electroconvulsive Therapy multisite study.

METHODS

A total of 624 patients were enrolled in an National Institute of Mental Health (NIMH)-funded, randomized, controlled ECT trial comparing the efficacy of continuation ECT versus continuation pharmacotherapy between 1997 and 2004. This analysis focuses on the 32 black and 483 white patients who participated in phase I of the study. The authors compared baseline demographic and clinical variables and acute outcomes of these 2 groups.

RESULTS

Compared with whites, far fewer blacks participated in the study. Those who did were less likely to have failed adequate medication trials and were more likely to have psychotic features. Their initial 24-item Hamilton Rating Scale for Depression scores were higher than those of the whites, and they showed a greater reduction in these 24-item Hamilton Rating Scale for Depression scores by the end of the treatment period. Although sample size limited the statistical significance of the findings, black patients also showed a higher rate of remission after an acute phase of ECT.

CONCLUSIONS

This study found that black and white patients with major depressive disorder had comparable outcomes. We also found that fewer black patients received ECT than whites, a difference that has been reported in other samples.

Electroconvulsive therapy, brain-derived neurotrophic factor, and possible neurorestorative benefit of the clinical application of electroconvulsive therapy

Treatment-resistant depression (TRD) is a growing problem in psychiatry. A recent meta-analysis has estimated TRD to be as high as 40%. Just over a decade ago, TRD was estimated to be as low as 10% to 15%. The causes of TRD are not fully understood. Finding ways to bring patients to remission faster may be part of the solution, but increasing our understanding of how depression works and how the brain responds to treatment may shed some light on this growing problem. Patients with TRD have been shown to have decreased volumes in gray matter structures, particularly in the hippocampus. Hippocampal volumes are correlated with decreased expression of neurotrophic factors (most notably, brain-derived neurotrophic factor [BDNF]), and decreased expression of BDNF correlates with the presence of depression. Increased expression of BDNF has a strong association with increased volumes in the hippocampus. Electroconvulsive therapy (ECT), a safe and effective treatment of severe depression, has been shown to be effective in TRD. Patients who undergo ECT have also had measurable increases in BDNF, indicating that ECT may be modulating intracellular processes in the patients with depression. Taken together, ECT may have a positive effect on restoring gray matter volume in patients with depression and especially TRD.

Continuation/maintenance treatment with nortriptyline versus combined nortriptyline and ECT in late-life psychotic depression: a two-year randomized study

OBJECTIVE

The identification of effective continuation and maintenance strategies for elderly patients with psychotic depression is a critical issue that has not been fully explored. The aim of this study was to assess the tolerability and efficacy of continuation/maintenance electroconvulsive therapy (ECT) in elderly patients with psychotic depression after acute ECT remission.

METHODS

The authors used a longitudinal, randomized, single-blind design to compare by survival analysis the 2-year outcome of two subgroups of elderly patients with psychotic unipolar depression who were ECT (plus nortriptyline) remitters. One group was treated with a continuation/maintenance nortriptyline regimen (N = 17) and the other with combined continuation/maintenance ECT plus nortriptyline (N = 16).

RESULTS

Over 2 years of treatment in elderly, psychotic, unipolar depressed ECT (plus nortriptyline) remitters, the mean survival time was significantly longer in the combined ECT plus nortriptyline subgroup than in the nortriptyline subgroup. No differences were observed between treatments with regard to tolerability.

CONCLUSIONS

This study supports the judicious use of combined continuation/maintenance ECT and antidepressant treatment in elderly patients with psychotic unipolar depression who are ECT remitters.

[Somatic therapies for treatment-resistant psychiatric disorders]

OBJECTIVE

This paper reviews the current knowledge of somatic treatment in psychiatry, with a focus on treatment-resistant psychiatric disorders.

METHOD

A computerized search of the literature was conducted on Medline using the words "electroconvulsive therapy", "transcranial magnetic stimulation", "vagus nerve stimulation", "deep brain stimulation" and "magnetic seizure therapy". References from each paper were also screened.

RESULTS

The development of new non-pharmacological psychiatric interventions in the past decades has renewed the clinical and research interest in somatic therapies. Although electroconvulsive therapy remains the only somatic treatment with undisputed efficacy, transcranial magnetic stimulation, magnetic seizure therapy, vagus nerve stimulation and deep brain stimulation all offer potential as novel means of psychiatric treatment.

CONCLUSIONS

New treatment modalities still have an insufficient body of data. Notwithstanding, biological strategies continue to hold promise as a safer and more effective approach to psychiatric treatment.

Strategies to minimize cognitive side effects with ECT: aspects of ECT technique

The adverse cognitive effects of electroconvulsive therapy are important limitations in the use of this treatment that continues to be a significant therapeutic strategy after 7 decades of use. Among the approaches to mitigation of these side effects are considerations involving the prescription and manipulation of the electrical stimulus itself. The impact of the following electrical factors on the cognitive outcomes of electroconvulsive therapy are surveyed: efficiency of the stimulus as expressed in electrical waveform; targeting of the stimulus, the major concept underlying electrode placement; stimulus dosing; and frequency and number of treatments. The current state of development of knowledge in these areas is summarized, and methods to achieve the best cognitive outcomes without sacrificing clinical efficacy are discussed. Future trends in the further optimization of the electrical stimulus are briefly mentioned.

The efficacy of acute electroconvulsive therapy in atypical depression

OBJECTIVE

This study examined the characteristics and outcomes of patients with major depressive disorder (MDD), with or without atypical features, who were treated with acute bilateral electroconvulsive therapy (ECT).

METHOD

Analyses were conducted with 489 patients who met DSM-IV criteria for MDD. Subjects were identified as typical or atypical on the basis of the Structured Clinical Interview for DSM-IV obtained at baseline prior to ECT. Depression symptom severity was measured by the 24-item Hamilton Rating Scale for Depression (HAM-D(24)) and the 30-item Inventory of Depressive Symptomatology-Self-Report (IDS-SR(30)). Remission was defined as at least a 60% decrease from baseline in HAM-D(24) score and a total score of 10 or below on the last 2 consecutive HAM-D(24) ratings. The randomized controlled trial was performed from 1997 to 2004.

RESULTS

The typical (N = 453) and atypical (N = 36) groups differed in several sociodemographic and clinical variables including gender (p = .0071), age (p = .0005), treatment resistance (p = .0014), and age at first illness onset (p < .0001) and onset of current episode (p = .0008). Following an acute course of bilateral ECT, a considerable portion of both the typical (67.1%) and the atypical (80.6%) groups reached remission. The atypical group was 2.6 (95% CI = 1.1 to 6.2) times more likely to remit than the typical group after adjustment for age, psychosis, gender, clinical site, and depression severity based on the HAM-D(24).

CONCLUSION

Acute ECT is an efficacious treatment for depressed patients with typical or atypical symptom features.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00000375.