Episode length and mixed features as predictors of ECT nonresponse in patients with medication-resistant major depression

Validity of the DSM-5 Mixed Features Specifier Interview

OBJECTIVES

To examine the reliability and validity of a semi-structured interview assessing the features of the DSM-5 mixed features specifier. Our goal was to develop an instrument that could be used for both diagnostic and severity measurement purposes.

METHODS

Four hundred fifty-nine psychiatric patients in a depressive episode were interviewed by a trained diagnostic rater who administered semi-structured interviews including the DSM-5 Mixed Features Specifier Interview (DMSI). We examined the inter-rater reliability and psychometric properties of the DMSI. The patients were rated on clinician rating scales of depression, anxiety, and irritability, and measures of psychosocial functioning, suicidality, and family history of bipolar disorder.

RESULTS

The DMSI had excellent joint-interview interrater reliability. More than twice as many patients met the DSM-5 mixed features specifier criteria during the week before the assessment than for the majority of the episode (9.4% vs. 3.9%). DMSI total scores were more highly correlated with a clinician-rated measure of manic symptoms than with measures of depression and anxiety. More patients with bipolar depression met the mixed features specifier than patients with MDD. Amongst patients with MDD, those with mixed features more frequently had a family history of bipolar disorder, were more frequently diagnosed with anxiety disorders, attention deficit disorder, and borderline personality disorder, more frequently had attempted suicide, and were more severely depressed, anxious, and irritable.

CONCLUSION

The DMSI is a reliable and valid measure of the presence of the DSM-5 mixed features specifier in depressed patients as well as the severity of the features of the specifier.

The impact of the number of previous illness episodes on early response to electroconvulsive therapy (ECT) in psychosis, mania, depression, psychotic depression, and catatonia: A naturalistic transdiagnostic analysis

Electroconvulsive Therapy (ECT) is an effective treatment for mood and psychotic disorders but there is growing evidence of treatment resistant to ECT. Our study aimed to investigate the relationship between the number of previous illness episodes and the symptomatic improvement after acute ECT treatment. We conducted a retrospective naturalistic cohort analysis of patients' ECT registry data from March 2017 to February 2023. We categorized the number of previous illness episodes into "0-3″ and ">3 episodes", paired T-tests were used to compare the changes in scores of clinical assessments, generalized linear models were used to analyze the association between the number of previous illness episodes and change in symptomatic scores. A total of 1137 patients were included for analysis. There was a significant global improvement in psychiatric symptoms (CGI) after 6 ECT treatments across five indications. We observed that compared to patients with less previous illness episodes, patients with more than 3 previous illness episodes had 30% lower chance of response to acute ECT treatment. Thus, our study suggests that use ECT earlier in the course of illness is associated with greater response and support offering ECT earlier in the disease course.

Electroconvulsive therapy for treatment-resistant depression

Electroconvulsive therapy (ECT), the oldest brain stimulation procedure in psychiatry, is associated with rapid response and remission in majority of patients with resistant, severe, and sometimes life-threatening depression. ECT has been included as an essential component in the definition of treatment-resistant depression (TRD) to display the course and diversification of TRD. On the other hand, ECT remains the treatment of choice for the most severe incapacitating forms of TRD and is a cost-effective treatment. In this chapter, we reviewed some essential studies, meta-analysis, and expert guidelines regarding ECT in TRD. ECT should not be considered as a treatment of last resort, and its administration should be considered on the basis of individual patient and illness factors. The clinical role of ECT vs other neurostimulation treatments for TRD, that is, repetitive transcranial magnetic stimulation, were also explored. Much effort has been directed toward the clinical and basic research about mechanisms of action of ECT in depression. A thorough understanding of the neurobiological effects of ECT may increase our understanding of its therapeutic effects, ultimately leading to improved patient care. We also showed that the distinct mechanisms of ECT in biological treatments of major depressive disorder (MDD) and some recent approaches to understand this most common psychiatric disorder. ECT should remain a standard part of modern psychiatric medicine. We recommend a more careful and thoughtful application of this traditional but effective technology.

Naturalistic Study on the Effects of Electroconvulsive Therapy (ECT) on Depressive Symptoms

OBJECTIVE

The effectiveness of ECT under naturalistic conditions has not been well-studied. The current study aimed to 1) characterize a naturalistic sample of ECT patients; and 2) examine the long-term outcomes of ECT on depressive symptoms (Beck Depression Inventory-II; BDI-II) and functional disability symptoms (WHO Disability Assessment Schedule 2.0) in this sample.

METHODS

Participants were adults who received ECT for a major depressive episode at an ambulatory ECT clinic between September 2010 and November 2020. Clinical and cognitive assessments were completed at baseline (n = 100), mid-ECT (n = 94), 2-4 weeks post-ECT (n = 64), 6-months post-ECT (n = 34), and 12-months post-ECT (n = 19).

RESULTS

At baseline, participants had severe levels of depressive symptoms (BDI-II: M = 41.0, SD = 9.4), and 62.9% screened positive for multiple psychiatric diagnoses on the MINI International Neuropsychiatric Interview. Depressive symptoms (F(4,49.1) = 49.92, P < 0.001) and disability symptoms (F(3,40.72) = 12.30, P < 0.001) improved significantly following ECT, and this was maintained at 12-months follow-up. Improvement in depressive symptoms trended towards significantly predicting reduction in disability symptoms from baseline to post-ECT, (F(1,56) = 3.67, P = 0.061). Although our clinical remission rate of 27% (BDI-II score ≤ 13 and ≥ 50% improvement) and overall response rate of 41.3% (≥ 50% improvement in BDI-II score) were lower than the rates reported in the extant RCT and community ECT literature, 36% of those treated with ECT were lost to follow-up and did not complete post-ECT rating scales. At baseline, remitters had significantly fewer psychiatric comorbidities, lower BDI-II scores, and lower disability symptoms than non-responders (P < 0.05).

CONCLUSIONS

Participants were severely symptomatic and clinically complex. ECT was effective at reducing depressive symptoms and functional disability in this heterogeneous sample. Although a large amount of missing data may have distorted our calculated response/remission rates, it is also likely that clinical heterogeneity and severity contribute to lower-than-expected remission and response rates to ECT.

Similar clinical improvement of depression using 0.5-ms and 1-ms pulse widths in bilateral electroconvulsive therapy

There is a lack of research regarding 0.5-ms pulse width (PW) in bilateral electroconvulsive therapy (ECT). The aim of this study was to compare the efficacy and number of treatment sessions between groups receiving 0.5-ms and 1-ms PW ECT. Ninety-four patients with unipolar major depression treated with acute bilateral ECT were analysed retrospectively, grouped as consecutive patients treated with 0.5-ms PW ECT (n = 47), and age- and sex-matched patients treated with 1-ms PW ECT. Clinical and ECT data were extracted from clinical records. Symptom evaluations and global cognitive screening at baseline and post-ECT were administered by trained psychiatrists. The Hamilton Rating Scale for Depression (HDRS-21) was rated weekly. Efficacy and number of treatment sessions were compared between groups. PW was explored as a predictor of mean decrease in HDRS and number of treatment sessions by regression models. Group characteristics did not differ at baseline. The mean decrease in HDRS in the 0.5- and 1-ms PW [25.85 (7.79) vs. 24.33 (6.99), respectively], response (95.7% vs. 97.9%), remission (87.2% vs. 80.9%) and mean number of treatment sessions [11.28 (3.85) vs. 11.34 (3.36)] were not significantly different. Episode duration and severity, and previous ECT predicted HDRS decrease. Severity at baseline and the 6th session, the dosing method and the last ECT treatment dose predicted the number of treatment sessions needed. PW was not significant in the regressions models. The results suggest that both PWs perform similarly in bilateral ECT for depression, resulting in equivalent antidepressant efficacy and number of treatment sessions needed.

Diagnosing and treating major depressive episodes that lie along the mood disorders spectrum: focus on depression with mixed features

Growing evidence indicates that historical descriptions of mixed depression-broadly defined as major depressive episodes with subthreshold manic or hypomanic (hypo/manic) symptoms-are incredibly clinically relevant in this day-and-age. However, the first operational definition of mixed depression did not occur in the modern nomenclature until 2013 with publication of Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), and there has not been enough time to evaluate these criteria empirically. Thus, the most valid operational definition of a mixed depressive episode is still unknown, widely accepted treatment guidelines are not available, and no treatment has regulatory approval for mixed depression-whether associated with bipolar I disorder, bipolar II disorder, or major depressive disorder. This is despite seven drugs having regulatory indications for mixed episodes, defined as the co-occurrence of syndromal depression and syndromal mania, and now recognized as mania with mixed features by DSM-5. Indeed, we found only two randomized, placebo-controlled trials in patients with protocol defined mixed depression, one with ziprasidone and one with lurasidone. Both studies were positive, suggesting treatment with second-generation antipsychotics may be helpful for mixed depressive episodes associated with bipolar II or unipolar disorder. We found no randomized control trial of antidepressant monotherapy in mixed depression and many clinical reports that such treatment may worsen mixed depression Randomized, placebo-controlled trials of antidepressants, antipsychotics, and mood stabilizers-alone and in combination-in individuals with carefully defined mixed depression are needed before firm treatment guidelines can be produced.

Bi-temporal electroconvulsive therapy efficacy in bipolar and unipolar depression: A retrospective comparison

AIM

Although electroconvulsive therapy (ECT) has been extensively used for depressive episodes in bipolar disorder (BDD), it has received less interest in research compared with major depressive disorder (MDD). Studies comparing the efficacy of ECT in BDD and MDD have been contradictory. This study aimed to compare the effectiveness of ECT in BDD and MDD, analyzing the influence of clinical features on outcome.

METHODS

The medical charts and electronic records of 107 patients (MDDn = 75 [70.1 %], BDD n = 32 [29.9 %]) receiving bi-temporal ECT were investigated retrospectively. Features of the index episode, such as the time elapsed until ECT and the effect of diagnosis on efficacy evaluated by the Hamilton Depression Rating Scale (HAM-D), were analyzed.

RESULTS

The diagnostic groups were alike concerning clinical features of the index episode, such as the presence of psychotic symptoms and suicidality. Patient age and the number of previous affective episodes were significantly different between the groups. The time elapsed until ECT in the examined episode was significantly longer in the MDD group. Compared with the MDD group, the BDD group had a significantly higher remission rate with ECT. Regression analysis revealed that BDD diagnosis, older age, and shorter time until ECT were significantly associated with remission.

CONCLUSION

The significant relationship observed between greater time elapsed until ECT and worse outcome is noteworthy in terms of clinical practice. This finding further challenges the widely accepted place of ECT as the "last resort" for the treatment of depression in bipolar and unipolar affective disorders.

Naturalistic follow-up in bipolar patients after successful electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is an effective treatment for acute depression, mania and mixed states. We evaluated the long-term outcome of patients with bipolar depression or mixed state, responsive to ECT.

METHODS

this observational follow-up study was conducted in 70 patients with Bipolar Disorder: 36 patients met DSM-IV-TR criteria for a major depressive episode (MDE) and 34 for a mixed episode (MXE). During the follow-up after ECT, the relapse rates and the duration of response and remission periods were recorded.

RESULTS

the mean duration of the follow-up was 57 weeks. 93% of the patients maintained at least a partial therapeutic response for more than 90% of the follow-up period. 73% of patients fulfilled the criteria for a full remission, 33% showed a depressive relapse and 10% a mixed relapse. No manic relapses occurred but almost 1/3 of the sample presented hypomanic episodes. MDE patients presented higher rates of remission compared to MXE ones. Patients with anxiety disorders reported earlier relapses than those without this comorbidity. Relapsed-patients showed higher functional impairment at baseline evaluation, compared to non-relapsed ones.

LIMITATIONS

nonrandom allocation, limited sample size, possible influence of psychopharmacological treatment.

CONCLUSIONS

Given several methodological limitations, this study cannot draw definite conclusions but could suggest that in treatment-resistant bipolar patients with severe depression or mixed state, ECT may represent a useful treatment option. Patients with mixed features, comorbid anxiety disorders and higher functional impairment present less favorable outcome. Future research on long-term efficacy of ECT and on clinical predictors of relapse is needed.

The CINP Guidelines on the Definition and Evidence-Based Interventions for Treatment-Resistant Bipolar Disorder

BACKGROUND

Resistant bipolar disorder is a major mental health problem related to significant disability and overall cost. The aim of the current study was to perform a systematic review of the literature concerning (1) the definition of treatment resistance in bipolar disorder, (2) its clinical and (3) neurobiological correlates, and (4) the evidence-based treatment options for treatment-resistant bipolar disorder and for eventually developing guidelines for the treatment of this condition.

MATERIALS AND METHODS

The PRISMA method was used to identify all published papers relevant to the definition of treatment resistance in bipolar disorder and the associated evidence-based treatment options. The MEDLINE was searched to April 22, 2018.

RESULTS

Criteria were developed for the identification of resistance in bipolar disorder concerning all phases. The search of the literature identified all published studies concerning treatment options. The data were classified according to strength, and separate guidelines regarding resistant acute mania, acute bipolar depression, and the maintenance phase were developed.

DISCUSSION

The definition of resistance in bipolar disorder is by itself difficult due to the complexity of the clinical picture, course, and treatment options. The current guidelines are the first, to our knowledge, developed specifically for the treatment of resistant bipolar disorder patients, and they also include an operationalized definition of treatment resistance. They were based on a thorough and deep search of the literature and utilize as much as possible an evidence-based approach.

The Role of Electroconvulsive Therapy in the Treatment of Severe Bipolar Mixed State

Electroconvulsive therapy (ECT) results effective in two-thirds of the patients with severe and drug-resistant mixed states. The episode duration is the main predictor of nonresponse. This practice may increase the risk of mood destabilization and chronic complications and may decrease the chance of recovery in many patients. Compared with the burden of neurologic and metabolic side effects associated with long-term use of complex pharmacologic regimens, ECT should be considered a safe option with a very low incidence of severe adverse events and a long-term nondestabilizing effect.

Can psychomotor disturbance predict ect outcome in depression?

Psychomotor symptoms are core features of melancholic depression. This study investigates whether psychomotor disturbance predicts the outcome of electroconvulsive therapy (ECT) and how the treatment modulates psychomotor disturbance. In 73 adults suffering from major depressive disorder psychomotor functioning was evaluated before, during and after ECT using the observer-rated CORE measure and objective measures including accelerometry and a drawing task. Regression models were fitted to assess the predictive value of melancholic depression (CORE ≥ 8) and the psychomotor variables on ECT outcome, while effects on psychomotor functioning were evaluated through linear mixed models. Patients with CORE-defined melancholic depression (n = 41) had a 4.9 times greater chance of reaching response than those (n = 24) with non-melancholic depression (Chi-Square = 7.5, P = 0.006). At baseline, both higher total CORE scores (AUC = 0.76; P = 0.001) and needing more cognitive (AUC = 0.78; P = 0.001) and motor time (AUC = 0.76; P = 0.003) on the drawing task corresponded to superior ECT outcomes, as did lower daytime activity levels (AUC = 0.76) although not significantly so after Bonferroni correction for multiple testing. A greater CORE-score reduction in the first week of ECT was associated with higher ECT effectiveness. ECT reduced CORE-assessed psychomotor symptoms and improved activity levels only in those patients showing the severer baseline retardation. Although the sample was relatively small, psychomotor symptoms were clearly associated with beneficial outcome of ECT in patients with major depression, indicating that monitoring psychomotor deficits can help personalise treatment.

Do baseline sub-threshold hypomanic symptoms affect acute-phase antidepressant outcome in outpatients with major depressive disorder? Preliminary findings from the randomized CO-MED trial

Sub-threshold hypomanic symptoms are common in major depressive disorder. This study evaluated the prevalence, the clinical and sociodemographic correlates, and the overall and differential effects of the presence/absence of sub-threshold hypomanic symptoms at baseline on acute-phase treatment outcomes with bupropion-plus-escitalopram combination, escitalopram monotherapy, and venlafaxine-plus-mirtazapine combination. Combining medications to enhance depression outcomes (CO-MED) trial participants (n = 665) were designated as sub-threshold hypomanic symptoms present (Altman Self-Rating Mania Scale score (ASRM) ≥ 1) or absent (ASRM = 0) and compared on clinical and sociodemographic features and remission rates. Participants with sub-threshold hypomanic symptoms (n = 335/665, 50.4%) were more likely to be black and non-Hispanic, have comorbid medical and psychiatric disorders, experience longer index episodes, and report lower depression severity and psychosocial impairment. Intent-to-treat remission rates were lower overall (absent = 42.7%, present = 34.0%, p = 0.02), with escitalopram monotherapy (absent = 45.8%, present = 31.6%, p = 0.03), and with venlafaxine-XR-plus-mirtazapine combination (absent = 44.4%, present = 30.1%, p = 0.03) but not with bupropion-plus-escitalopram combination (absent = 37.7%, present = 40.0%, p = 0.73). Participants without sub-threshold hypomanic symptoms were more likely to remit than those with such symptoms overall [odds ratio (OR) = 1.49], with escitalopram monotherapy (OR = 1.71), and with venlafaxine-plus-mirtazapine combination (OR = 1.97) but not with bupropion-plus-escitalopram combination (OR = 0.96), even after controlling for baseline depression severity, psychosocial impairment, and number of comorbid psychiatric disorders. Sub-threshold hypomanic symptoms (found in about 50% of patients in this report) were associated with lower remission rates with escitalopram monotherapy and with venlafaxine-plus-mirtazapine combination but not with the bupropion-plus-escitalopram combination.

Electroconvulsive therapy and age: Age-related clinical features and effectiveness in treatment resistant major depressive episode

OBJECTIVE

This study was aimed to compare clinical features, treatments outcomes and tolerability between young (18-45 years), middle age (46-64 years) and old (≥ 65 years) patients treated with bilateral ECT for treatment resistant major depressive episode.

METHOD

402 patients were evaluated 1 day prior to ECT and a week after the treatment termination using the Clinical Global Impression Scale (CGI), the Hamilton Rating Scale for Depression-17 items (HAM-D-17), the Brief Psychiatric Rating Scale (BPRS), the Young Mania Rating Scale (YMRS) and the Mini Mental State Examination (MMSE). Response was defined as a reduction of at least 50% from baseline on the HAM-D-17 score. Remission was defined as a score ≤ 7 on the HAM-D-17 at the final evaluation.

RESULTS

Rates of response were not statistically different in the three groups (69.6% in old versus 63.5% in young and 55.5% in middle age groups). No significant differences were also observed in the proportions of remitters between the age groups (31.4% in young group, 27.7% in middle age group and 29.3% in old group). One week after the end of the ECT course the middle and old age groups showed a statistically significant increase in the MMSE score compared to baseline. We did not find significant differences between the three age groups in rates of premature drops-out due to ECT-related side effects.

CONCLUSION

Our data support the use of ECT in elderly patients with treatment-resistant major depressive episode, with rates of response around 70% and effectiveness being independent from age. In the old age group the baseline cognitive impairment improved after ECT and no life-threatening adverse event was detected.

Longer depressive episode duration negatively influences HF-rTMS treatment response: a cerebellar metabolic deficiency?

Repetitive transcranial magnetic stimulation (rTMS) is an evidence based neurostimulation modality used to treat patients with Major Depressive Disorder (MDD). In spite that the duration of current a depressive episode has been put forward as a negative predictor for clinical outcome, little is known about the underlying neurobiological mechanisms of this phenomenon. To address this important issue, in a sample of 43 melancholic stage III treatment resistant antidepressant-free refractory MDD patients, we reanalysed regional cerebral glucose metabolism (CMRglc) before high frequency (HF)-rTMS treatment, applied to the left dorsolateral prefrontal cortex (DLPFC). Besides that a lower baseline cerebellar metabolic activity indicated negative clinical response, a longer duration of the depressive episode was a negative indicator for recovery and negatively influenced cerebellar CMRglc. This exploratory ¹⁸FDG PET study is the first to demonstrate that the clinical response of HF-rTMS treatment in TRD patients may depend on the metabolic state of the cerebellum. Our observations could imply that for left DLPFC HF-rTMS non-responders other brain localisations for stimulation, more specifically the cerebellum, may be warranted.

Blood homocysteine concentration and mood disorders with mixed features among patients with alcohol use disorder

BACKGROUND

Blood homocysteine concentration (BHC) is higher in patients with alcohol use disorder (AUD). Previous studies have found a relationship between depressive symptoms severity and BHC in AUD patients and recently some authors have found high BHC among patients with bipolar disorder, both during manic and depressive episodes and in euthymic state. However, BHC in patients with mixed mood episode has not yet been investigated. The aim of this study was to evaluate the BHC of patients with AUD and mixed mood episode.

METHODS

A sample of AUD outpatients was assessed by Mini-International Neuropsychiatric Interview (MINI Plus): those with a DSM-IV-TR mood disorder with mixed features were included in the MIXED group (n = 45), whereas those without mood episode were gathered in the NO MOOD group (n = 23). Two subgroups, MIXMANIA and MIXDEPRESSION, were formed according to the prevalence of manic or depressive symptoms, assessed by Young Mania Rating Scale (YMRS), and Hamilton Rating Scale for Depression (HDRS). The Alcohol Use Disorder Identification Test (AUDIT) was used to appraise the AUD. BHC was determined by High-Performance Liquid Chromatography.

RESULTS

The MIXED group showed greater severity of both depressive (26.35 ± 9.96 vs. 4.77 ± 0.92; p < 0.001) and manic (22.35 ± 3.30 vs. 6.14 ± 1.12; p < 0.001) symptoms, and higher BHC (28.80 ± 11.47 vs. 10.83 ± 2.81; p < 0.001), than the NO MOOD group. BHC was strongly correlated to the HDRS, YMRS and AUDIT scores, just as HDRS was to YMRS, and AUDIT was to both HDRS and YMRS, in the MIXED group only (p < 0.001). The MIXDEPRESSION subgroup showed higher BHC than the MIXMANIA subgroup (Mdn = 42.96, IQR = 10.44 vs. Mdn = 19.77, IQR = 5.93; p < 0.001). A linear regression model conducted on the MIXED group found a significant predictive value for BHC of both HDRS (β = 0.560, t = 2.43, p = 0.026) and AUDIT (β = 0.348, t = 2.17, p = 0.044).

CONCLUSIONS

Depressive symptoms seem to be mainly implicated in the BHC elevation among patients with both mixed features mood disorder and AUD.

Clinical factors related to acute electroconvulsive therapy outcome for patients with major depressive disorder

The aim of this study was to explore the significant predictors associated with electroconvulsive therapy (ECT) outcome for patients with major depressive disorder. Major depressive disorder inpatients (N=130) requiring ECT were recruited from a major psychiatric center in South Taiwan. ECT was generally performed for a maximum of 12 sessions. Symptom severity was assessed using the 17-item Hamilton Depression Rating Scale (HAMD-17) and Clinical Global Impression of Severity (CGI-S) before ECT, after every three ECT sessions, and after the last ECT. The generalized estimating equations method was used to analyze the influence of potential variables over time on the HAMD-17 and CGI-S, respectively. Fourteen patients not completing the first three sessions of ECT were excluded. The remaining 116 patients were included in the analysis. Patients with treatment-resistant depression, longer duration of the current depressive episode, and higher levels of pain were more likely to have less symptom reduction after acute treatment with ECT, irrespective of how the depressive symptoms were rated using HAMD-17 or CGI-S. To improve efficacy, earlier application of ECT and pain control should be considered during an acute course of ECT. Other clinical predictors related to ECT outcome require further investigation in future studies.

Sensory Processing Disorders are Associated with Duration of Current Episode and Severity of Side Effects

OBJECTIVE

Longer duration of untreated illness, longer duration of current episode, and the severity of medication side effects may negatively impact on the perceived disability and psychosocial impairment of patients with major affective and anxiety disorders. Studies also suggested the involvement of sensory perception in emotional and psychopathological processes. The present study aimed to examine the relationship between Sensory Processing Disorders (SPD), duration of untreated illness and current illness episode, and the severity of side effects related to psychoactive medications.

METHODS

The sample included 178 participants with an age ranging from 17 to 85 years (mean=53.84±15.55). Participants were diagnosed with unipolar Major Depressive Disorder (MDD) (50%), Bipolar Disorder (BD) (33.7%), and Anxiety disorders (16.3%). They completed a socio-demographic questionnaire, the Udvalg for Kliniske Undersøgelser (UKU), and Adolescent/Adult Sensory Profile (AASP) questionnaire.

RESULTS

Longer duration of current episode correlated with greater registration of sensory input and lower avoidance from sensory input among unipolar patients; with lower registration of sensory input, and higher tendency for sensory sensitivity/avoidance among bipolar participants; with lower sensory sensitivity/avoidance among anxiety participants, respectively. Also, mean UKU total scores correlated with lower sensory sensitivity among bipolar individuals.

CONCLUSION

SPD expressed in either hypo/hyper sensitivity may serve to clinically characterize subjects with major affective and anxiety disorders.

Clinical subtypes of severe bipolar mixed states

OBJECTIVE

The aim of the present study was to identify different clinical subtypes in severe, treatment resistant bipolar mixed state (MS).

METHOD

The sample comprised 202 Bipolar I patients currently in MS referred for an Electro-convulsive Therapy (ECT) trial and evaluated in the first week of hospitalization and one week after the ECT course. Principal component factor analysis (PCA) followed by Varimax rotation was performed on 21 non-overlapping items selected from Hamilton rating-scale for depression (HAMD) and from Young mania rating-scale (YMRS) at baseline evaluation. Cluster subtypes derived from the factor scores were compared in clinical variables and final HAMD, YMRS, Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression (CGI) scores.

RESULTS

The principal-component analysis extracted 6 interpretable factors explaining 55.9% of the total variance. Cluster analysis identified four groups, including respectively 63 (31.2%) subjects with Agitated-Irritable Mixed-Depression, 59 (29.2%) with Psychotic Mixed-Mania, 17 (8.5%) with Anxious-Irritable-Psychotic Mixed-Mania, and 63 (31.2%) with Retarded-Psychotic Mixed-Depression. The four clusters were statistically distinct and did not show significant overlap in the main symptomatological presentation. Cluster subtypes reported differences in number of past mood episodes, duration of the current episode, suicide attempts, lifetime comorbidity with panic and eating disorders, baseline and final rating-scale scores and rate of remission after ECT trial.

CONCLUSIONS

Our study indicates that, at least in severe treatment resistant MS, multiple depressive and manic subtypes can be observed with substantial differences in terms of clinical presentation, course, associated comorbidities and treatment response.

Do benzodiazepines moderate the effectiveness of bitemporal electroconvulsive therapy in major depression?

BACKGROUND

Electroconvulsive therapy (ECT) is the most effective treatment for depression. However, the use of concomitant medications during ECT is controversial, especially benzodiazepines, as some past evidence suggests these may reduce the efficacy of ECT. This study analysed the effect of benzodiazepines on treatment outcomes in a group of depressed patients treated with bitemporal (BT) ECT.

METHODS

90 patients with major depression who received BT ECT were analysed. Clinical, demographic and ECT data were extracted from clinical records. Mood improvement was rated by trained psychiatrists using the Hamilton Depression Rating Scale (HDRS-21) at baseline and after the final ECT treatment. The association between benzodiazepine dose and mood outcomes over the ECT course was examined with regression analyses, controlling for variables that may affect ECT efficacy.

RESULTS

Hierarchical multiple regression analysis found only current episode duration (t=-4.77, p<0.001) was a significant predictor of change in HDRS. Benzodiazepine dose was not associated with a change in HDRS (p>0.05, R(2)=0.39).

LIMITATIONS

This was a retrospective study. The use of the half-age dosing method for ECT did not permit examination of the effects of benzodiazepines on seizure threshold.

CONCLUSIONS

Benzodiazepines did not affect the efficacy of BT ECT with the dosing method used. However, these results may not generalise to other forms of ECT, ECT given with other methods of dose determination or to other populations less responsive to ECT.

Neuromodulation therapies and treatment-resistant depression

Background

Patients with treatment-resistant depression (TRD) who showed partial response to pharmacological and psychotherapeutic interventions need a trial of neuromodulation therapies (NTs).

Objective

This paper aims to review evidence-based data on the use of NTs in TRD.

Method

Using keywords and combined-word strategy, multiple computer searches of PubMed, Google Scholar, Quertle(R), and Medline were conducted for retrieving relevant articles published in English-language peer-reviewed journals (2000–2012). Those papers that addressed NTs in TRD were retained for extensive review.

Results

Despite methodological challenges, a range of 30%–93% of TRD patients showed substantial improvement to one of the NTs. One hundred–percent improvement was reported in two single-case studies on deep brain stimulation. Some studies reported no benefits from transcranial direct current stimulation. NTs were reported to have good clinical efficacy, better safety margin, and benign side-effect profile. Data are limited regarding randomized clinical trials, long-term efficacy, and cost-effectiveness of these approaches. Both modified electroconvulsive therapy and magnetic seizure therapy were associated with reversible but disturbing neurocognitive adverse effects. Besides clinical utility, NTs including approaches on the horizon may unlock the biological basis underlying mood disorders including TRD.

Conclusion

NTs are promising in patients with TRD, as the majority of them show good clinical response measured by standardized depression scales. NTs need further technological refinements and optimization together with continuing well-designed studies that recruit larger numbers of participants with TRD.

Treatment-resistant depression: therapeutic trends, challenges, and future directions

BACKGROUND

Patients with major depression respond to antidepressant treatment, but 10%-30% of them do not improve or show a partial response coupled with functional impairment, poor quality of life, suicide ideation and attempts, self-injurious behavior, and a high relapse rate. The aim of this paper is to review the therapeutic options for treating resistant major depressive disorder, as well as evaluating further therapeutic options.

METHODS

In addition to Google Scholar and Quertle searches, a PubMed search using key words was conducted, and relevant articles published in English peer-reviewed journals (1990-2011) were retrieved. Only those papers that directly addressed treatment options for treatment-resistant depression were retained for extensive review.

RESULTS

Treatment-resistant depression, a complex clinical problem caused by multiple risk factors, is targeted by integrated therapeutic strategies, which include optimization of medications, a combination of antidepressants, switching of antidepressants, and augmentation with non-antidepressants, psychosocial and cultural therapies, and somatic therapies including electroconvulsive therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy, deep brain stimulation, transcranial direct current stimulation, and vagus nerve stimulation. As a corollary, more than a third of patients with treatment-resistant depression tend to achieve remission and the rest continue to suffer from residual symptoms. The latter group of patients needs further study to identify the most effective therapeutic modalities. Newer biomarker-based antidepressants and other drugs, together with non-drug strategies, are on the horizon to address further the multiple complex issues of treatment-resistant depression.

CONCLUSION

Treatment-resistant depression continues to challenge mental health care providers, and further relevant research involving newer drugs is warranted to improve the quality of life of patients with the disorder.