Influence of depressed patients' expectations prior to electroconvulsive therapy on its effectiveness and tolerability (Exp-ECT): a prospective study

Treatment expectations and clinical outcomes following repetitive transcranial magnetic stimulation for treatment-resistant depression

BACKGROUND

Patient expectations, including both positive (placebo) and negative (nocebo) effects, influence treatment outcomes, yet their impact on acute repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant depression (TRD) is unclear.

METHODS

In this single-center retrospective chart review, 208 TRD patients completed the Stanford Expectation of Treatment Scale (SETS) before starting open-label rTMS treatment. Patients were offered two excitatory rTMS protocols (deep TMS or intermittent theta-burst stimulation), which stimulated the left dorsolateral prefrontal cortex. A minimum of 20 once daily treatments were provided, delivered over 4-6 weeks. Primary outcomes were 1) remission, measured by a post-treatment score of <8 on the Hamilton Depression Rating Scale (HAMD-17), and 2) premature discontinuation. The change in HAMD-17 scores over time was used as a secondary outcome. Physicians were blinded to SETS scores. Logistic and linear regression, adjusting for covariates, assessed SETS and HAMD-17 relationships.

RESULTS

Of 208 patients, 177 had baseline and covariate data available. The mean positivity bias score (positive expectancy minus negative expectancy subscale averages) was 0.48 ± 2.21, indicating the cohort was neutral regarding the expectations of their treatment on average. Higher positive expectancy scores were significantly associated with greater odds of remission (OR = 1.90, p = 0.003) and greater reduction in HAMD-17 scores (β = 1.30, p = 0.005) at the end of acute treatment, after adjusting for covariates. Negative expectancy was not associated with decreased odds of remission (p = 0.2) or treatment discontinuation (p = 0.8).

CONCLUSIONS

Higher pre-treatment positive expectations were associated with greater remission rates with open-label rTMS in a naturalistic cohort of patients with TRD.

A comparison of the safety, feasibility, and tolerability of ECT and ketamine for treatment-resistant depression

INTRODUCTION

Treatment-resistant depression (TRD) is a problematic and prevalent public health and societal concern. Although electroconvulsive therapy (ECT) is the gold standard TRD intervention, the treatment evokes apprehension due to public perceptions, feasibility, and tolerability. Despite significant medical advancements, few medications have been approved by the U.S. Food and Drug Administration for TRD. In 2019, intranasal esketamine, the S-isomer of racemic ketamine, was approved for TRD, garnering significant excitement about the potential for the drug to act as an alternative treatment to ECT.

AREAS COVERED

The goal of this narrative review is to compare the safety, efficacy, and tolerability of ketamine and ECT; clarify whether ketamine is a reasonable alternative to ECT; and to facilitate improved treatment assignment for TRD. Empirical quantitative and qualitative studies and national and international guidelines these treatments are reviewed.

EXPERT OPINION

: The field awaits the results of two ongoing large comparative effectiveness trials of ECT and IV ketamine for TRD, which should help guide clinicians and patients as to the relative risk and benefit of these interventions. Over the next five years we anticipate further innovations in neuromodulation and in drug development which broadly aim to develop more tolerable versions of ECT and ketamine, respectively.

Satisfaction and attitude of bipolar patients regarding electroconvulsive therapy: modified or unmodified

Objective: Ministry of Health of Turkey issued a legislation to use only modified electroconvulsive therapy (ECT) in 2005, and this study aimed to assess satisfaction and attitude of bipolar patients regarding modified and unmodified electroconvulsive therapy.Methods: A total of 100 patients (50 treated with modified electroconvulsive therapy (M-ECT) and 50 treated with unmodified ECT (UM-ECT) with a diagnosis of Bipolar Disorder (depressive or manic episode) were invited to participate in this study. Patients with euthymic mood were included. Satisfaction and attitude towards ECT were evaluated with a structured attitude questionnaire, and M-ECT and UM-ECT patients, and their subgroups (depressive vs. manic) were compared.Results: No significant differences were found between M-ECT and UM-ECT groups regarding age, sex, marital status and occupation. The majority of all patients (78%) were satisfied from treatment with ECT and with the outcome (88%), without significant differences between modified and unmodified groups. Forgetfulness (70%) and headaches (57%) occurred in all groups, with the only significant difference in forgetfulness being reported by more manic patients treated with UM-ECT. Depressive and manic patients treated with UM-ECT reported concerns of brain damage and physical harm significantly more frequently. While 86% of patients treated with M-ECT consented to a future treatment, this was significantly less in patients treated with UM-ECT (50%).Conclusions: Bipolar patients report a high degree of satisfaction treated either with modified or unmodified ECT but there was a significant difference in perception of adverse effects and willingness for receiving ECT in future.

Serum neurofilament light chain (NFL) remains unchanged during electroconvulsive therapy

Objectives: Although there is consistent evidence that electroconvulsive therapy (ECT) is safe and well tolerated by the majority of patients, some authors still accuse ECT to inevitably cause brain damage and permanent memory loss, assertions that may increase patients' worries about a useful treatment. Recently, the measurement of neurofilament light chain (NFL) in peripheral blood was technically implemented, permitting longitudinal analysis of this biomarker for axonal damage. NFL is part of the axonal cytoskeleton and is released into the CSF and peripheral blood in the context of neuronal damage.Methods: In our study, blood from 15 patients with major depressive disorder receiving ECT was collected before the first ECT as well as 24 h and seven days after the last ECT, respectively. NFL concentrations were analysed using the ultrasensitive single molecule array (Simoa) technology.Results: NFL concentrations did not differ between patients and healthy controls, and there was no significant change in NFL levels in the course of ECT. On the contrary, we even found a slight decrease in absolute NFL concentrations.Conclusions: Our study confirms the safety of ECT by using a most sensitive method for the detection of NFL in peripheral blood as a biomarker of neuronal damage.

[Effectiveness and tolerability of electroconvulsive therapy : Influence of clinical response from the patient's point of view]

BACKGROUND

Electroconvulsive therapy (ECT) is a highly effective, yet still controversial therapy for both the general public and psychiatrists. In this study, we investigated the patients’ view regarding effectiveness and tolerability of electroconvulsive therapy under consideration of individual clinical response.

MATERIAL AND METHODS

In 31 patients with major depression, subjective effectiveness and tolerability were assessed via a differentiated questionnaire prior to, during, and after ECT. Symptoms were rated using the Montgomery-Åsberg depression rating scale (MADRS) and the Beck depression inventory II (BDI-II).

RESULTS

Patients assessed ECT to be generally effective both before and after the treatment. This view was independent of their individual treatment success. In contrast, patients’ rating of individual effectiveness depended on the objective improvement of their symptoms. Side effects were rated to be generally slight to moderate.

CONCLUSION

Against the background of persisting criticism towards ECT, the viewpoint of involved patients provides us with important references for an appropriate judgement of this therapy. The results suggest a good benefit-risk ratio for ECT from the patients’ perspective.