Factors associated with relapse after a response to electroconvulsive therapy in unipolar versus bipolar depression

[Impact of the diagnostic method for borderline personality disorder on the acute response and the risk of early relapse in major depressed individuals treated with ECT: A systematic literature review]

INTRODUCTION

Given the contradictory data available in the literature, the aim of this systematic review was to investigate the impact of the diagnostic method for borderline personality disorder (BPD) on the acute response and the risk of early relapse in major depressed individuals treated with electroconvulsive therapy (ECT).

METHOD

After a systematic literature review performed during March 2023 in the PubMed-Medline database according to the PRISMA criteria, 47 articles were identified using the keyword algorithm ("Electroconvulsive Therapy" [Mesh] or electroconvulsive therapy) and ("Borderline Personality Disorder" [Mesh] or borderline personality disorder). The inclusion criteria applied for the selection of articles in this systematic review were: (1) articles investigating the impact of BPD on the acute response and/or the risk of early relapse in major depressed individuals (> 18 years old) treated with ECT, (2) diagnosis of BPD and major depressive disorder by validated screening tests and/or systematic psychiatric interviews based on diagnostic criteria of international classification, (3) any type of study (cross-sectional, longitudinal, prospective, retrospective, interventional and experimental), (4) articles written in English or French, and (5) articles published after January 2000. After assessment of the 47 articles based on these inclusion criteria by two authors, seven studies investigating the impact of BPD diagnosed by systematic psychiatric interview or screening tests on the acute response and the risk of early relapse in major depressed individuals treated with ECT were included in this systematic review.

RESULTS

Unlike the three studies diagnosing BPD by screening tests, the four studies diagnosing BPD by systematic psychiatric interview demonstrated a negative impact of this personality disorder on the acute response or the risk of early relapse in major depressed individuals treated with ECT. However, all studies included in this systematic review presented a low level of scientific evidence (cross-sectional epidemiological studies and retrospective cohort studies).

CONCLUSION

Despite the need for studies of better scientific quality, the results of this systematic review seem to indicate that screening for BPD by systematic psychiatric interview during the pre-ECT assessment and the establishment of adequate therapeutic strategies in case of comorbid BPD could be promising options to allow better acute response and better prevention of early relapses in major depressed individuals treated with ECT.

Risk of relapse within 6 months associated with borderline personality disorder in major depressed individuals treated with electroconvulsive therapy

Given the limited data in the literature, the aim of this study was to investigate the risk of relapse within 6 months associated with borderline personality disorder (BPD) in major depressed individuals treated with electroconvulsive therapy. Demographic and clinical data from 109 major depressed individuals with partial or complete response to electroconvulsive therapy recruited from the database of the Psychiatry Department of Erasme Hospital were analysed. Cox regression analyses were used to determine the risk of relapse within 6 months associated with BPD in major depressed individuals treated with electroconvulsive therapy. Relapses within 6 months were frequent (37.6%) in our sample of major depressed individuals treated with electroconvulsive therapy. After adjusting for major confounding factors, multivariate Cox regression analyses demonstrated that BPD was a risk factor for relapse within 6 months in major depressed individuals treated with electroconvulsive therapy. In our study, we demonstrated that BPD is associated with higher risk of relapse within 6 months in major depressed individuals treated with electroconvulsive therapy, which seems to justify a more systematic screening for BPD in order to allow the implementation of more effective prevention strategies for relapse within 6 months in this particular subpopulation.

Individual response to electroconvulsive therapy is not correlated between multiple treatment courses

OBJECTIVES

Electroconvulsive therapy (ECT) effectively treats depressive disorders, but many patients will have subsequent relapses. While some guidelines suggest prior response to ECT is an indication for ECT in a subsequent mood episode, it is unknown whether response to ECT is correlated between treatment courses. This study explores whether response to ECT at a first treatment correlates with response to treatment in a second independent ECT course.

METHODS

Single-center retrospective cohort of patients receiving two different ECT treatment courses between 2011 and 2020 and who self-reported depression symptoms using the Quick Inventory of Depressive Symptomatology (QIDS) at baseline and following treatment #5.

RESULTS

286 patients received two independent ECT series during the study period, of whom 153 received at least 5 treatments in both series. Patients had similar QIDS scores at the start of each treatment series (Pearson's correlation, r = 0.58, p <0.001), but the change in QIDS following 5 ECT treatments was not correlated between series for individual patients (Pearson's correlation, r = 0.083, p = 0.31). In multivariate analyses, change in QIDS was similar for both treatment series, but patients were less likely to receive 5 treatments in the second treatment series.

LIMITATIONS

retrospective cohort cannot control for factors influencing access to repeat ECT treatment CONCLUSIONS: While on average final QIDS score was the same following two independent treatment courses, for individual patients the change in depression symptoms was not correlated between treatment series. Further research is needed to identify factors that may predict longitudinal ECT response.

Factors causing a relapse of major depressive disorders following successful electroconvulsive therapy: A retrospective cohort study

BACKGROUND

Electroconvulsive therapy (ECT) is used to treat major depressive disorder (MDD). Relapse is often observed even after successful ECT, followed by adequate pharmaceutical treatment for MDD.

AIM

To investigate the diagnostic factors and treatment strategies associated with depression relapse.

METHODS

We analyzed the relationships between relapse, the diagnostic change from MDD to bipolar disorder (BP), and treatment after the initial ECT. We performed a 3-year retrospective study of the prognoses of 85 patients of the Shiga University of Medical Science Hospital. The relative risk of relapse of depressive symptoms was calculated based on the diagnostic change from MDD to BP. A receiver operating characteristic (ROC) curve was generated to evaluate the predictive accuracy of diagnostic changes from MDD to BP based on the duration between the first course of ECT and the relapse of depressive symptoms.

RESULTS

Eighty-five patients initially diagnosed with MDD and successfully treated with ECT were enrolled in the study. Compared with the MDD participants, more BP patients experienced relapses and required continuation and/or maintenance ECT to maintain remission (65.6% vs 15.1%, P < 0.001; relative risk = 4.35, 95%CI: 2.19-8.63, P < 0.001). Twenty-nine patients experienced relapses during the three-year follow-up. In 21 (72.4%, 21/29) patients with relapse, the diagnosis was changed from MDD to BP. The duration from the first course of ECT to relapse was shorter for the BP patients than for the MDD patients (9.63 ± 10.4 mo vs 3.38 ± 3.77 mo, P = 0.022); for most patients, the interval was less than one month. The relative risk of depressive symptoms based on diagnostic changes was 4.35 (95% confidence interval: 2.19–8.63, P < 0.001), and the area under the ROC curve for detecting diagnostic changes based on relapse duration was 0.756 (95%CI: 0.562-0.895, P = 0.007).

CONCLUSION

It may be beneficial to suspect BP and change the treatment strategy from MDD to BP for patients experiencing an early relapse.

Relapse following bitemporal and high-dose right unilateral electroconvulsive therapy for major depression

OBJECTIVE

Electroconvulsive therapy (ECT) is an effective acute treatment for severe and/or medication-resistant depression but maintaining remission following completion of a course remains a clinical challenge.

METHODS

EFFECT-Dep Trial (ISRCTN23577151) participants with a DSM-IV major depressive episode who met remission criteria after a randomly assigned course of twice-weekly brief-pulse bitemporal (1.5 × seizure threshold) or high-dose (6 × seizure threshold) right unilateral ECT were monitored for relapse for 12 months. In line with the pragmatic trial design, all patients received treatment-as-usual individualised pharmacotherapy during and after ECT; no remitter received continuation ECT.

RESULTS

Of 61 remitters, 24 (39.3%) relapsed, one (1.6%) withdrew from the study while in remission and the remaining 36 (59.0%) stayed well for a year. Most relapses occurred within the first six months, resulting in a cumulative six-month relapse rate of 31.1%. In a multivariable Cox proportional hazards regression model, older age (p = 0.039) and psychotic features at pre-ECT baseline (p = 0.037) were associated with a more favourable long-term prognosis while a greater number of previous depressive episodes (p = 0.028) and bipolar II (but not bipolar I) diagnosis (p = 0.030) were associated with a worse long-term outcome. Electrode placement and medication resistance prior to ECT had no effect on relapse. Adjusting for covariates, fewer patients treated with lithium relapsed in the overall group (p = 0.008) and in the unipolar depression subgroup (p = 0.027).

CONCLUSION

Long-term outcome following high-dose right unilateral ECT does not differ from bitemporal ECT. Prognosis is particularly favourable in older adults, psychotic depression and patients maintained on lithium.

Does lithium prevent relapse following successful electroconvulsive therapy for major depression? A systematic review and meta-analysis

OBJECTIVE

The risk of relapse following successful antidepressant treatment, including electroconvulsive therapy (ECT), is substantial. Lithium has been suggested to effectively prevent relapse, yet data remain limited and inconclusive. We performed a systematic review and meta-analysis to examine the efficacy of continuation treatment with lithium in preventing relapse following a successful acute course of ECT in patients with major depression, in comparison to continuation treatment without lithium. We also assessed the role of several study characteristics, possibly impacting the treatment effect.

METHODS

A systematic literature search, using the PubMed, Embase, Web of Science, and Cochrane Library databases (up to June 2020), was conducted for prospective and retrospective studies, including patients with unipolar or bipolar depression, that assessed the efficacy of lithium for post-ECT depressive relapse prevention.

RESULTS

Of 2556 records screened, 14 articles reporting on 9748 participants who received continuation treatment either with (N = 1571) or without lithium (N = 8177) were included in the meta-analysis. Patients receiving lithium were less likely to experience depressive relapse after a successful acute course of ECT, compared to patients receiving post-ECT prophylaxis without lithium (weighted odds ratio (OR) = 0.53, 95% confidence interval (CI) = 0.34, 0.82), with a number needed to treat (NNT) of 7 (95% CI = 4, 21). We found some limited evidence that older patients may benefit more from continuation treatment with lithium, compared to younger patients. Using the GRADE criteria, the quality of evidence for our outcome measure (i.e., relapse rate) was rated as very low.

CONCLUSION

Continuation treatment with lithium may have superior efficacy in reducing the risk of relapse after a successful acute ECT course for major depression, in comparison to continuation treatment without lithium. High-quality studies are needed to confirm this finding.

Psychotic late-life depression less likely to relapse after electroconvulsive therapy

BACKGROUND

A substantial number of patients with late-life depression (LLD) that remitted after ECT experience relapse. Identifying risk factors for relapse may guide clinical management to devote attention to those at increased risk. Therefore the current study aims to evaluate which baseline clinical characteristics are related to relapse within six months after successful ECT in patients with severe LLD.

METHODS

110 patients with LLD from the prospective naturalistic follow-up Mood Disorders in Elderly treated with Electro-Convulsive Therapy (MODECT) study were included. A total of 73 patients (66.4%) remitted after ECT, six patients had missing information on relapse, rendering to a total sample size of 67 patients. Relapse within six months after ECT was defined as a Montgomery Åsberg Depression Scale (MADRS)-score > 15, readmission or restart of ECT. Logistic regression analyses were conducted to examine the association between baseline clinical characteristics and relapse.

RESULTS

A total of 22 patients (32.8%) experienced a relapse. Patients with psychotic depression were less likely to relapse (odds ratio = 0.32, p = .047), corrected for prior admissions; 76.9% of patients with psychotic depression remained remitted.

LIMITATIONS

Due to its naturalistic design, no firm conclusions can be drawn on the effect of post-ECT treatment.

CONCLUSIONS

Patients with psychotic depression had a lower risk to experience relapse after successful ECT. This result strengthens the hypothesis that psychotic depression might be a specific depression subtype with a favorable ECT outcome up to six months after ECT.

Comparison of the efficacy of electroconvulsive therapy (ECT) plus agomelatine to ECT plus placebo in treatment-resistant depression

OBJECTIVE

Electroconvulsive therapy (ECT) is commonly used to treat patients with treatment-resistant depression. We aimed to investigate whether combining an antidepressant agent with ECT might enhance therapeutic efficacy and prevent early relapse.

METHOD

During the acute ECT phase, patients (N = 97) with treatment-resistant depression were randomized to receive ECT plus agomelatine 50 mg/day (n = 48) or ECT plus placebo (n = 49). Symptom severity measures, including the 17-item Hamilton Depression Rating Scale (HAMD-17) and other scales, functional impairment, quality of life, neuropsychological tests, adverse events and attitudes toward ECT, were assessed regularly. Remission was defined as a HAMD-17 score ≤7. If patients achieved post-ECT remission, they were prescribed agomelatine 50 mg/day and participated in a 12-week follow-up trial. HAMD-17 was rated at 4-week intervals. Relapse was defined as a HAMD-17 score ≥14, or rehospitalization for a psychiatric reason.

RESULTS

The two treatment groups were comparable at (i) baseline variables; (ii) score changes in all symptom measures, functional impairment, quality of life, and neuropsychological tests; (iii) frequency of adverse events and attitudes toward ECT; and (iv) post-ECT response/remission rates. There were no statistically significant differences following ECT in relapse rates and time to relapse between these two groups.

CONCLUSION

Adding agomelatine to ECT yielded comparable response/remission rates to ECT without agomelatine in the acute ECT phase. Starting agomelatine in combination with ECT did not seem to be more efficacious in preventing relapse than starting agomelatine after the acute ECT course. More research is needed to guide clinical recommendations.

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.

Risk Factors of Relapse After Successful Electroconvulsive Therapy for Taiwanese Patients With Major Depression

OBJECTIVES

Major depressive disorder is a recurrent illness. Treatment strategies are generally focused on achieving remission and preventing relapse/recurrence. The aim of this study was to explore the risk factors associated with relapse for remitted patients during the 12-week follow-up.

METHODS

This was an open-label trial for major depressive disorder patients receiving acute treatments with electroconvulsive therapy (ECT) and continuation medication in the 12-week follow-up. Symptom severity and psychosocial functioning were assessed using the 17-item Hamilton Rating Scale for Depression (HAMD-17) and the Work and Social Adjustment Scale at each visit. Remission was defined as a HAMD-17 of 7 or less after acute treatment. Relapse was defined as a HAMD-17 of 14 or greater. Subjects achieving remission after acute treatments were included for analysis. Survival analysis was used to investigate the factors associated with relapse.

RESULTS

Sixty patients receiving ECT for acute treatment were enrolled for 12-week follow-up. Using Cox regression analysis, a greater number of previous major depressive episodes and greater baseline Work and Social Adjustment Scale scores were significantly associated with shorter time to relapse.

CONCLUSIONS

The goal of acute treatment should focus on functional remission to prevent relapse. Further studies related to more effective treatments to prevent relapse after acute ECT are required in the future.

The identification, assessment and management of difficult-to-treat depression: An international consensus statement

BACKGROUND

Many depressed patients are not able to achieve or sustain symptom remission despite serial treatment trials - often termed "treatment resistant depression". A broader, perhaps more empathic concept of "difficult-to-treat depression" (DTD) was considered.

METHODS

A consensus group discussed the definition, clinical recognition, assessment and management implications of the DTD heuristic.

RESULTS

The group proposed that DTD be defined as "depression that continues to cause significant burden despite usual treatment efforts". All depression management should include a thorough initial assessment. When DTD is recognized, a regular reassessment that employs a multi-dimensional framework to identify addressable barriers to successful treatment (including patient-, illness- and treatment-related factors) is advised, along with specific recommendations for addressing these factors. The emphasis of treatment, in the first instance, shifts from a goal of remission to optimal symptom control, daily psychosocial functional and quality of life, based on a patient-centred approach with shared decision-making to enhance the timely consideration of all treatment options (including pharmacotherapy, psychotherapy, neurostimulation, etc.) to optimize outcomes when sustained remission is elusive.

LIMITATIONS

The recommended definition and management of DTD is based largely on expert consensus. While DTD would seem to have clinical utility, its specificity and objectivity may be insufficient to define clinical populations for regulatory trial purposes, though DTD could define populations for service provision or phase 4 trials.

CONCLUSIONS

DTD provides a clinically useful conceptualization that implies a search for and remediation of specific patient-, illness- and treatment obstacles to optimizing outcomes of relevance to patients.

Bipolar depression: a major unsolved challenge

Depression in bipolar disorder (BD) patients presents major clinical challenges. As the predominant psychopathology even in treated BD, depression is associated not only with excess morbidity, but also mortality from co-occurring general-medical disorders and high suicide risk. In BD, risks for medical disorders including diabetes or metabolic syndrome, and cardiovascular disorders, and associated mortality rates are several-times above those for the general population or with other psychiatric disorders. The SMR for suicide with BD reaches 20-times above general-population rates, and exceeds rates with other major psychiatric disorders. In BD, suicide is strongly associated with mixed (agitated-dysphoric) and depressive phases, time depressed, and hospitalization. Lithium may reduce suicide risk in BD; clozapine and ketamine require further testing. Treatment of bipolar depression is far less well investigated than unipolar depression, particularly for long-term prophylaxis. Short-term efficacy of antidepressants for bipolar depression remains controversial and they risk clinical worsening, especially in mixed states and with rapid-cycling. Evidence of efficacy of lithium and anticonvulsants for bipolar depression is very limited; lamotrigine has long-term benefit, but valproate and carbamazepine are inadequately tested and carry high teratogenic risks. Evidence is emerging of short-term efficacy of several modern antipsychotics (including cariprazine, lurasidone, olanzapine-fluoxetine, and quetiapine) for bipolar depression, including with mixed features, though they risk adverse metabolic and neurological effects.

Potential predictors of depressive relapse following repetitive Transcranial Magnetic Stimulation: A systematic review

BACKGROUND

Repetitive Transcranial Magnetic Stimulation (rTMS) is widely approved treatment for major depressive disorder (MDD). However, around 50% of individuals who recover from depression following rTMS interventions experience a relapse of depressive symptomatology by 12 months. The short-term durability of the rTMS treatment effect has been systematically investigated. However, variables relating to the long-term durability of the antidepressant effect produced by rTMS are less understood. Therefore, the current review systematically assessed the research on variables relating to relapse following rTMS.

METHOD

This systematic review was performed according to PRISMA guidelines. A comprehensive electronic literature search for terms related to relapse following rTMS treatment for MDD was performed on studies published before the end of October 2018.

RESULTS

A total of 18 studies assessing relapse related variables were identified. While there is some indication that comorbid anxiety, acute response, and residual symptomatology may hold predictive potential for depressive relapse following rTMS treatment, findings were not sufficient to draw reliable conclusions.

DISCUSSION

Identified studies assessed three main categories of variables including demographic information, clinical characteristics and rating scale scores, and rTMS treatment specific factors. Only a small number of studies were available, and considerable inconsistency exists between studies, only limited conclusions were able to be drawn.

CONCLUSION

More studies assessing a wider range of predictor variables such as cognitive or neuroimaging markers are needed.

Clinical outcome after discontinuation of maintenance Electroconvulsive Therapy. A retrospective follow-up study

INTRODUCTION

Continuation and maintenance electroconvulsive therapy (c/m-ECT) is a therapeutic option after an acute ECT course. Although it is widely used, both duration and the outcome of patients when ECT-c/m is discontinued is not yet well established. The aim of the study was to evaluate the recurrence rate and associated clinical factors when c/m-ECT is discontinued.

MATERIALS AND METHODS

Retrospective evaluation of 73 patients who were discontinued from c/m-ECT. The minimum evaluation time was one year. The need of hospital admission or a new acute course of ECT was considered a relapse. The recurrence rate was calculated as a percentage and the estimated time to recurrence was analyzed through a survival analysis. Possible associations between clinical variables and recurrence were analyzed by univariate and multivariate Cox analysis.

RESULTS

Thirty-six patients (49.3%) relapsed: 61.1% of them relapsed during the first year after the c/m-ECT discontinuation (36.1% during the first 6 months). The estimated time to recurrence was 38.67 months. Fifty percent of patients who relapsed required a new acute course of ECT and 44.4% of them restarted c/m-ECT. Patients with an interval between sessions of less than one month and those with more previous episodes showed a higher risk of recurrence.

CONCLUSIONS

The risk of recurrence should be considered before the discontinuation of c/m-ECT. After the discontinuation, almost half of the patients relapsed, most of them within the first year. Close monitoring should be conducted in these patients and the discontinuation is not recommended when it is administered at intervals between sessions of less than a month. Further studies are required to identify risk groups for relapse.

Shared preventive factors associated with relapse after a response to electroconvulsive therapy in four major psychiatric disorders

AIM

The efficacy of electroconvulsive therapy (ECT) has been established in psychiatric disorders but the high rate of relapse is a critical problem. The current study sought preventative factors associated with relapse after a response to ECT in a continuum of four major psychiatric disorders.

METHODS

The records of 255 patients with four psychiatric disorders (83 unipolar depression, 60 bipolar depression, 91 schizophrenia, 21 schizoaffective disorder) were retrospectively reviewed.

RESULTS

The relapse-free rate of all patients at 1 year was 56.3% in the four psychiatric disorders without a difference. As a result of univariate analysis, three items could be considered as preventative factors associated with relapse: a small number of psychiatric symptom episodes before an acute course of ECT, the use of mood stabilizers, and the use of maintenance ECT. Multivariate analysis was performed, keeping age, sex, and diagnosis constant in addition to the three items, and small number of psychiatric symptom episodes before an acute course of ECT (P = 0.003), the use of lithium (P = 0.025), the use of valproate (P = 0.027), and the use of maintenance ECT (P = 0.001) were found to be significant preventative measures against relapse.

CONCLUSION

The use of mood stabilizers, such as lithium and valproate, and maintenance ECT could be shared preventive factors associated with relapse after a response to ECT in four major psychiatric disorders.

Reduced Serum and Cerebrospinal Fluid Levels of Autotaxin in Major Depressive Disorder

BACKGROUND

The autotaxin/lysophosphatidic acid axis is involved in diverse biological processes including neurodevelopment, inflammation, and immunological functioning. The lysophosphatidic acid 1 receptor has been implicated in the pathophysiology of major depressive disorder and in the mechanism of action of antidepressants. However, it is unclear whether central or peripheral autotaxin levels are altered in patients with major depressive disorder.

METHODS

Serum autotaxin levels were measured by an enzyme-linked immunosorbent assay in 37 patients with major depressive disorder diagnosed using DSM-IV-TR who underwent electroconvulsive therapy and were compared with those of 47 nondepressed controls matched for age and sex between January 2011 and December 2015. Patient serum levels of autotaxin before and after electroconvulsive therapy were also compared. In a separate sample set, cerebrospinal fluid autotaxin levels were compared between 26 patients with major depressive disorder and 27 nondepressed controls between December 2010 and December 2015. A potential association was examined between autotaxin levels and clinical symptoms assessed with the Hamilton Depression Rating Scale.

RESULTS

Before electroconvulsive therapy, both serum and cerebrospinal fluidautotaxin levels were significantly lower in major depressive disorder patients than in controls (serum: P = .001, cerebrospinal fluid: P = .038). A significantly negative correlation between serum, but not cerebrospinal fluid, autotaxin levels and depressive symptoms was observed (P = .032). After electroconvulsive therapy, a parallel increase in serum autotaxin levels and depressive symptoms improvement was observed (P = .005).

CONCLUSION

The current results suggest that serum autotaxin levels are reduced in a state-dependent manner. The reduction of cerebrospinal fluidautotaxin levels suggests a dysfunction in the autotaxin/lysophosphatidic acid axis in the brains of patients with major depressive disorder.

Pharmacological treatment of adult bipolar disorder

We summarize evidence supporting contemporary pharmacological treatment of phases of BD, including: mania, depression, and long-term recurrences, emphasizing findings from randomized, controlled trials (RCTs). Effective treatment of acute or dysphoric mania is provided by modern antipsychotics, some anticonvulsants (divalproex and carbamazepine), and lithium salts. Treatment of BD-depression remains unsatisfactory but includes some modern antipsychotics (particularly lurasidone, olanzapine + fluoxetine, and quetiapine) and the anticonvulsant lamotrigine; value and safety of antidepressants remain controversial. Long-term prophylactic treatment relies on lithium, off-label use of valproate, and growing use of modern antipsychotics. Lithium has unique evidence of antisuicide effects. Methods of evaluating treatments for BD rely heavily on meta-analysis, which is convenient but with important limitations. Underdeveloped treatment for BD-depression may reflect an assumption that effects of antidepressants are similar in BD as in unipolar major depressive disorder. Effective prophylaxis of BD is limited by the efficacy of available treatments and incomplete adherence owing to adverse effects, costs, and lack of ongoing symptoms. Long-term treatment of BD also is limited by access to, and support of expert, comprehensive clinical programs. Pursuit of improved, rationally designed pharmacological treatments for BD, as for most psychiatric disorders, is fundamentally limited by lack of coherent pathophysiology or etiology.

Rehospitalization and suicide following electroconvulsive therapy for bipolar depression-A population-based register study

BACKGROUND

Electroconvulsive therapy (ECT) is effective in bipolar depression, but relapse is common. The aim of the study was (i) to identify prognostic factors (ii) and to determine the impact of pharmacological approaches on the risk for rehospitalization or suicide.

METHODS

This register study analyzed data from individuals treated with inpatient ECT for bipolar depression. Subjects were identified using the Swedish National Patient Register between 2011 and 2014 and the Swedish National Quality Register for ECT. Other national registers provided data on psychopharmacotherapy, socio-demographic factors, and causes of death. The endpoint was the composite of rehospitalization for any psychiatric disorder, suicide attempt or completed suicide (RoS). Cox regression was used to calculate hazard ratios in univariate and multivariate models.

RESULTS

Data from 1255 patients were analyzed. The mean period of follow-up was 346 days. A total of 29%, 41%, and 52% of patients reached RoS at 3, 6, and 12 months post-discharge. A history of multiple psychiatric admissions, lower age, and post-discharge treatment with antipsychotics or benzodiazepines was associated with RoS.

LIMITATIONS

Indication bias may have affected the results.

CONCLUSIONS

A history of multiple hospital admissions and lower age are key predictors of the composite of rehospitalization or suicide in patients treated with ECT for bipolar depression. Lithium might be effective. By contrast, antipsychotics and benzodiazepines were associated with increased risk, but possibly this finding was influenced by indication bias.

Possible Association between Serum Matrix Metalloproteinase-9 (MMP-9) Levels and Relapse in Depressed Patients following Electroconvulsive Therapy (ECT)

BACKGROUND

Matrix metalloproteinases are involved in neuroinflammatory processes, which could underlie depression. Serum levels of MMP-9 and MMP-2 in depressed patients are significantly altered following electroconvulsive therapy, but an association between altered matrix metalloproteinases after successful ECT and possible relapse has yet to be investigated.

METHODS

Serum was obtained twice, before and immediately after a course of electroconvulsive therapy, from 38 depressed patients. Serum was also collected, once, from two groups of age- and gender-matched healthy controls, 40 volunteers in each group. Possible associations between levels of matrix metalloproteinases and relapse during a 1-year follow-up period were analyzed.

RESULTS

Excluding patients who did not respond to electroconvulsive therapy and patients lost to follow-up, data from 28 patients were evaluated. Eighteen of the patients (64.3%) relapsed within 1 year. In the group that did not relapse, serum levels of MMP-9 were significantly decreased after a course of electroconvulsive therapy, but not in the group that relapsed. No association between MMP-2 and relapse was observed.

CONCLUSION

The degree of change in serum MMP-9 change could be associated with relapse following electroconvulsive therapy in depressed patients.