Which residual symptoms predict relapse after successful electroconvulsive therapy for late-life depression?

Challenges in maintaining remission after ECT - Insights from a six-month follow up study

INTRODUCTION

Electroconvulsive therapy (ECT) is a widely recognized treatment for severe depressive disorders, particularly in cases of inadequate response to pharmacological interventions or when rapid symptom relief is essential. Although ECT demonstrates high efficacy, a notable proportion of patients relapse after a successful ECT course.

METHODS

This study investigated clinical baseline characteristics and residual depressive symptoms associated with relapse - defined as a Montgomery-Åsberg Depression Rating Scale (MADRS) score >15, restart of ECT, or suicide attempt - within six months after successful ECT. Data were obtained from the PROTECT study, a single-site, prospective cohort study conducted at the University Psychiatric Center Duffel, Belgium.

RESULTS

- Among the 65 patients who completed the ECT course, 40 patients (62%) achieved remission. At six months, 32 patients were reassessed, and 18 (56%) of them experienced relapse. No significant associations were identified between relapse and baseline factors, including age, social circumstances, baseline depression severity, psychomotor symptoms, cognitive functioning, treatment resistance, lithium use, or the presence of psychotic or melancholic features. Residual depressive symptoms at the end of the ECT course also did not predict relapse.

DISCUSSION

- The observed high relapse rate underscores the critical need for robust continuation and maintenance strategies following ECT. Future research should prioritize larger cohorts to better identify predictors of relapse and optimize post-ECT treatment protocols.

MADRS single items differential changes among patients with melancholic and unspecified depression treated with ECT: an exploratory study

Introduction

Major depressive disorder (MDD) exhibits heterogeneity in treatment response.

Objective

This exploratory analysis aims to evaluate the differential changes in individual items of the MADRS between melancholic MDD (M-MDD) and unspecified MDD (U-MDD) following electroconvulsive therapy (ECT).

Methods

The study included 23 patients with unipolar MDD who received ECT. Patients were classified as M-MDD or U-MDD according to DSM-5 criteria. MADRS scores were assessed at baseline and one-month post-ECT. Differences between subtypes were analyzed using the Wilcoxon test and multiple linear regression.

Results

Among 23 participants receiving ECT for MDD, 10 had M-MDD and 13 had U-MDD. Baseline MADRS items showed significantly higher scores in the M-MDD group, except for reported sadness, suicidal ideation, and concentration difficulties. Total MADRS score reduction was significantly greater in the M-MDD group. This decline was especially pronounced in M-MDD patients for specific items, including apparent sadness, inability to feel, pessimistic thoughts, sleep disturbances, reduced appetite, and concentration difficulties, after adjusting for age and sex.

Conclusion

MADRS score reductions were more substantial for M-MDD than U-MDD in both total and specific items following one month of ECT. Further research with larger samples is needed to clarify MADRS response differences after ECT between melancholic and unspecified depressive subtypes.

The Search for Consistency in Residual Symptoms in Major Depressive Disorder: A Narrative Review

Residual symptoms are prevalent in major depressive disorder (MDD), encompassing a wide spectrum of symptoms such as sleep disturbances, changes in weight and appetite, cognitive impairment, and anxiety. These symptoms consistently impair daily functioning, diminish quality of life, and forecast disease relapse. Despite their clinical significance, residual symptoms lack a unified definition, potentially leading to confusion with treatment-emergent symptoms and ambiguity across studies, thereby hindering the generalizability of research findings. While some research identifies insomnia and mood disturbances as critical indicators, other studies emphasize different symptoms or find no significant correlation. Inconsistencies in defining residual symptoms, as well as methodological differences across studies, contribute to these conflicting results. While clinicians focus on alleviating negative symptoms to improve functional status, patients often prioritize achieving positive affect and overall well-being as essential components of successful treatment. It necessitates a comprehensive approach to patient care in depression. This review explores the phenomenon of residual symptoms in MDD, focusing on the ambiguity in definitions, clinical characteristics, and their impact on long-term outcomes. The lack of a standardized regulatory or academic definition for residual symptoms leads to varied interpretations among clinicians, underscoring the need for standardized terminology to guide effective treatment strategies and future research.

Identifying the core residual symptom in patients with major depressive disorder using network analysis and illustrating its association with prognosis: A study based on the national cohorts in China

OBJECTIVE

To identify the core residual symptom of MDD and assess its relationship with patients' long-term outcomes.

METHOD

All patients were administered antidepressants during the acute phase and treated continuously. The 521 patients remitted at month 6 of a multicenter prospective project were included. Remission was defined as a Quick Inventory of Depressive Symptoms-Self-Report total score of ≤5. Functional impairments were measured with the Sheehan Disability Scale, quality of life with the Quality of Life Enjoyment and Satisfaction Questionnaire - short form, and family burden with the Family Burden Scale of Disease. Visits were scheduled at baseline, weeks 2, 8, 12, and month 6.

RESULTS

Difficulty with concentration/decision making was the core residual symptom of MDD, determined with the centrality measure of network analysis. It was positively associated with functional impairments and family burden (r = 0.35, P < 0.01 and r = 0.31, P < 0.01, respectively) and negatively associated with life satisfaction (r = -0.29, P < 0.01). The exhibition of this residual symptom was associated with a family history of psychiatric disorders (OR = 2.610 [1.242-5.485]).

CONCLUSIONS

The core residual symptom of MDD, difficulty with concentration/decision making, is associated with poorer social functioning, heavier family burden, and lower life satisfaction. Early detection and intervention of this symptom may be beneficial.

CLINICAL TRIALS REGISTRATION NUMBER

(Chinese Clinical Trials.gov identifier) ChiCTR-OOC-17012566 and ChiCTR-INR-17012574.

Residual symptoms following electroconvulsive therapy: A retrospective cohort study

BACKGROUND

Residual depressive symptoms following treatment are a burden for patients and are associated with increased risk of relapse. While this phenomenon has been explored following pharmacotherapy, there is little research into residual symptoms following electroconvulsive therapy (ECT). This study quantifies the frequency and type of residual symptoms following ECT treatment.

METHODS

This study used retrospective data from patients receiving ECT as part of routine clinical care. Depressive symptomatology was assessed using the Quick Inventory of Depressive Symptomatology - Self-Report 16 item scale (QIDS), which includes 9 symptom domains graded from 0 to 3. We quantified the frequency of mild or greater (QIDS≥1) and moderate or greater (QIDS ≥ 2) residual symptoms following treatment among patients responding to ECT (QIDS decrease ≥50 % from baseline) and non-responders (QIDS decrease <50 %).

RESULTS

Among 1799 patients, 1015 (56.4 %) responded to ECT and 784 (43.6 %) did not. Among responders, 99.5 % had at least one residual symptom of mild severity or greater (median = 5, IQR = 3-6) and 83.3 % had at least one residual symptom of moderate severity or greater (median = 1, IQR = 1-2). Among non-responders, 100 % had residual symptoms of mild severity or greater (median = 8, IQR = 7-9), and 99.2 % had a residual symptom of moderate severity or greater (median = 4, IQR = 3-5). The most common residual symptoms among both responders and non-responders were sleep disturbances (93.1 % and 98.7 %, respectively) and sadness (68.9 % and 96.4 %, respectively).

LIMITATIONS

Retrospective data from a single freestanding psychiatric hospital.

CONCLUSION

Among patients with depression receiving ECT, there were high rates of residual symptoms even among patients responding to treatment.