Response rate and safety of antidepressants combined with electroconvulsive therapy in adolescent depression: Real-world clinical application

Use of Electroconvulsive Therapy Treatment in Adolescents in Singapore

BACKGROUND

Electroconvulsive therapy (ECT) is a highly effective treatment for schizophrenia and mood disorders; however, most evidence is derived from the adult population, with less evidence in adolescents. We sought to determine the use of ECT in adolescents in the Institute of Mental Health (IMH) and evaluate the treatment outcome.

METHODS

We conducted a retrospective naturalistic analysis of ECT registry data of patients aged from 10 to 19 years from March 2017 to March 2023. Descriptive analysis was used to analyze the demographics and clinical characteristics. Paired t tests were used to compare the change in clinical outcome scores, including the Brief Psychiatric Rating Scale (BPRS), Montgomery-Asberg Depression Rating Scale (MADRS), Clinical Global Impressions Scale - Severity (CGI-S), and Montreal Cognitive Assessment (MoCA) before and after 2 weeks of ECT treatment.

RESULTS

Fifty-five patients were included for analysis. There was a significant improvement in BPRS (P < 0.001), MADRS (P = 0.005), and CGI-S (P < 0.001), and the average CGI-I score was 2.275 (SD, 0.81), which is equivalent to "much improved" after 6 sessions of treatment. Of all patients, 48.5% showed significant clinical improvement. There was no significant change in MoCA scores (P = 0.218).

CONCLUSIONS

Our preliminary findings show that ECT is a safe, rapid, and effective treatment for psychotic and mood disorders in adolescents. Further studies with a larger sample size and specific subgroup analysis are needed to establish the effectiveness of ECT and identify predictors of response in this population.

Pediatric suicide: Review of a preventable tragedy

Concepts of suicide are explored in this issue with a focus on suicide in children and adolescents. The epidemiology of pediatric suicide in the United States is reviewed; also, risk and protective factors, as well as prevention strategies, are discussed. Suicide in the pediatric athlete and the potential protective effect of exercise are examined. In addition, this analysis addresses the beneficial role of psychological management as well as current research on pharmacologic treatment and brain stimulation procedures as part of comprehensive pediatric suicide prevention. Though death by suicide in pediatric persons has been and remains a tragic phenomenon, there is much that clinicians, other healthcare professionals, and society itself can accomplish in the prevention of pediatric suicide as well as the management of suicidality in our children and adolescents.

Synergistic use of deep TMS therapy with IV ketamine infusions for major depressive disorder: a pilot study

OBJECTIVE

Major Depressive Disorder (MDD) is a pervasive psychiatric condition effecting approximately 21 million adults in the U.S. (8.4%). An estimated 30-60% of patients are resistant to traditional treatment approaches (medications and talk-therapy), alluding to the need for additional options. Two promising treatment modalities include transcranial magnetic stimulation (TMS) and ketamine infusions; both have shown efficacy in standalone studies but have scarcely been investigated synergistically in the same group of participants.

METHOD

In the current study, 169 participants with treatment-resistant MDD received 36 treatments of Deep TMS-only (H1 + H7 protocols), while 66 received 36 treatments of Deep TMS (H1 + H7 protocols) and 6 IV infusions of ketamine over the course of 9 weeks. Depressive symptoms were compared pre- and -post treatment in both conditions using the PHQ-9.

RESULTS

In both treatment groups, depressive symptoms were significantly reduced from pre-to-post and there were no significant differences in response between the TMS + ketamine condition and the TMS-only condition. The TMS + ketamine condition had an 80.30% response rate (53 out of 66) and 43.42% remission rate (28 out of 66) compared to a 76.92% response (130 out of 169) and 39.64% remission (67 out of 16) in the TMS-only condition.

CONCLUSION

These results support the notion that TMS treatments yield high response rates in treatment-resistant cases; however, in this investigation there was no added benefit for including 6 sessions of IV ketamine in conjunction with TMS. Future investigations using randomized-control designs and robust outcome measures are warranted.

Novel rapid treatment options for adolescent depression

There is an urgent need for novel fast-acting antidepressants for adolescent treatment-resistant depression and/or suicidal risk, since the selective serotonin reuptake inhibitors that are clinically approved for that age (i.e., fluoxetine or escitalopram) take weeks to work. In this context, one of the main research lines of our group is to characterize at the preclinical level novel approaches for rapid-acting antidepressants for adolescence. The present review summarizes the potential use in adolescence of non-pharmacological options, such as neuromodulators (electroconvulsive therapy and other innovative types of brain stimulation), as well as pharmacological options, including consciousness-altering drugs (mainly ketamine but also classical psychedelics) and cannabinoids (i.e., cannabidiol), with promising fast-acting responses. Following a brief analytical explanation of adolescent depression, we present a general introduction for each therapeutical approach together with the clinical evidence supporting its potential beneficial use in adolescence (mainly extrapolated from prior successful examples for adults), to then report recent and/or ongoing preclinical studies that will aid in improving the inclusion of these therapies in the clinic, by considering potential sex-, age-, and dose-related differences, and/or other factors that might affect efficacy or long-term safety. Finally, we conclude the review by providing future avenues to maximize treatment response, including the need for more clinical studies and the importance of designing and/or testing novel treatment options that are safe and fast-acting for adolescent depression.