DSM melancholic features are unreliable predictors of ECT response: a CORE publication

Does theta burst stimulation have differential benefit for those with melancholic or non-melancholic depression?

BACKGROUND

To determine if theta burst stimulation (TBS) is of preferential benefit to those with melancholic or non-melancholic depression as an adjunctive treatment for treatment resistant depression (TRD).

METHODS

Fifty-two patients receiving TBS at a private psychiatric hospital participated in a naturalistic study. Four diagnostic strategies were used to assign melancholic versus non-melancholic depression subtype status. Depression symptoms were assessed at baseline, mid-treatment, and end of treatment using the Montgomery-Ǻsberg Depression Rating Scale - Self-Assessment (MADRS-S). Forty-one participants also completed the MADR-S at a six-week follow-up assessment.

RESULTS

We quantified poor correlations between the four study measures of melancholia; a finding suggesting that valid measurement of melancholia is likely to remain problematic. TBS led to significant reductions in depression symptoms from baseline to end of treatment, with this effect maintained at follow up. Response rates for the whole sample were 61.5 % at end of treatment and 53.7 % at follow-up, while remission rates were 34.6 % at end of treatment and 31.7 % at follow-up. Improvement rates as well as responder and remission rates were comparable for the melancholic and non-melancholic groups, irrespective of the diagnostic strategy used.

LIMITATIONS

The study was naturalistic (i.e., there being no control group, and concomitant medication changes were allowed), depression severity was assessed only by use of self-report measures, and the sample size was relatively small.

CONCLUSION

TBS appears to be non-specific, in that we failed to quantify any statistically significant differential benefit for those with melancholic compared to those with non-melancholic depression.

Catatonia and melancholia interface: exploring a new paradigm for evaluation and treatment. A case series and literature review

Background

Catatonia has been increasingly associated with mood disorders and is recognized as a specifier in the DSM-5 and DSM-5-TR. The DSM-5-TR recognizes melancholia as a specifier for depressive episodes in major depressive disorder and bipolar disorder. It is characterized by severe anhedonia, lack of reactivity, excessive or delusional guilt, and significant vegetative symptoms. As the conceptualization of melancholia expanded beyond its mood components to include psychomotor disturbances, its overlap with psychomotor symptoms or catatonia becomes evident. This overlap was also described in Kahlbaum's original literature, where he describes the transition between states of melancholia, mania, and catatonia.

Method

Case summary of six patients with major depressive disorder or depressed phase of bipolar disorder who were admitted for severe depression, anhedonia, intense anxiety, psychomotor agitation or retardation, indecisiveness, perseveration, and vegetative symptoms such as poor sleep, appetite, and significant weight loss.

Results

All patients demonstrated rapid and complete resolution of their mood and psychomotor symptoms, indecisiveness, perseveration, as well as psychosis shortly after administration of lorazepam, with recurrence of the above symptoms upon lorazepam discontinuation and resolution upon resumption, in an on-and-off manner.

Conclusion

The present study argues for a closer relationship between melancholia and catatonia based on our case series, historical review, overlap in phenomenology, and response to treatment. We propose provisional [Mahgoub] criteria for patients with severe depression and melancholia. The role of GABA agonists, such as lorazepam, can be explored as an option for patients with treatment-resistant depression who meet these criteria for melancholia.

Limitations

Absence of a standardized, systematic assessment tool and a small sample size.

Dynamics of Depressive and Psychomotor Symptoms During Electroconvulsive Therapy in Older Depressive Patients: A Case Series

OBJECTIVE

Electroconvulsive therapy (ECT) is an effective treatment for patients experiencing a major depressive episode, especially older ones. Identification of specific responses within early ECT sessions remains an issue of debate, however. Hence, this pilot study prospectively examined the outcome in terms of depressive signs, symptom by symptom, throughout a course of ECT, concentrating particularly on psychomotor retardation symptoms.

METHODS

Nine patients were clinically evaluated several times during the ECT course, before the first session and then weekly (over 3-6 weeks, according to their evolution), by completing the Montgomery-Åsberg Depression Rating Scale (MADRS), the Mini-Mental State Examination test, and the French Retardation Rating Scale for Depression for assessing the severity of psychomotor retardation.

RESULTS

Nonparametric Friedman tests showed significant positive changes in mood disorders during ECT in older depressive patients (mean, -27.3% of initial MADRS total score). Fast improvement in French Retardation Rating Scale for Depression score was observed at t1 (ie, after 3-4 ECT sessions), whereas a slightly delayed improvement in the MADRS scores was found at t2 (ie, after 5-6 ECT sessions). Moreover, the scores for items linked to the motor component of psychomotor retardation (eg, gait, postural control, fatigability) were the first to significantly decrease during the first 2 weeks of the ECT course compared with the cognitive component.

CONCLUSIONS

Interestingly, participants' concentration on daily functional activities, their interest and fatigability, and their reported state of sadness were the first to progress, representing possible precursor signs of positive patient outcomes after ECT.

What Can We Tell About the Effect of Electroconvulsive Therapy on the Human Hippocampus?

Electroconvulsive therapy (ECT) is the most effective antidepressant treatment, although its mechanisms of action remain unclear. Since 2010, several structural magnetic resonance imaging studies based on a neuroplastic hypothesis have consistently reported increases in the hippocampal volume following ECT. Moreover, volume increases in the human dentate gyrus, where neurogenesis occurs, have also been reported. These results are in line with the preclinical findings of ECT-induced neuroplastic changes, including neurogenesis, gliogenesis, synaptogenesis, and angiogenesis, in rodents and nonhuman primates. Despite this robust evidence of an effect of ECT on hippocampal plasticity, the clinical relevance of these human hippocampal changes continues to be questioned. This narrative review summarizes recent findings regarding ECT-induced hippocampal volume changes. Furthermore, this review also discusses methodological considerations and future directions in this field.

The utility of the Sydney Melancholia Prototype Index (SMPI) for predicting response to electroconvulsive therapy in depression: A CARE Network study

An enhanced understanding of clinical predictors of positive ECT outcome could assist with the decision to prescribe ECT for select patients. Reliable predictors of ECT response such as psychotic symptoms and age have been identified, however, studies of melancholia and ECT response have been inconsistent. The Sydney Melancholia Prototype Index (SMPI) is a clinical measure designed to differentiate melancholic and non-melancholic depression. This study aimed to investigate whether melancholic depression (as measured by the clinician rated version of the SMPI) predicted a better response to ECT than non-melancholic depression. The study included data collated from four participating sites in the Clinical Alliance for ECT and Related treatments (CARE) network. The primary outcome was response (>50% improvement) on the Montgomery Asberg Depression Rating Scale (MADRS) and the secondary outcome was raw change in MADRS score. Of the 329 depressed patients included in the study, 81% had melancholic features and 76% met criteria for clinical response. SMPI defined melancholia was associated with older age, higher pre-treatment mood scores and presence of psychosis. Melancholia as defined by the SMPI, however, did not significantly predict either clinical response or overall mood improvement with ECT in multivariate analyses. Instead, older age, greater pre-treatment depression severity and the use of bifrontal compared to right unilateral ultrabrief ECT were significant predictors of mood improvement. Path analysis showed that higher pre-treatment mood score and older age were independently associated with mood improvement with ECT.

Circadian depression: A mood disorder phenotype

Major mood syndromes are among the most common and disabling mental disorders. However, a lack of clear delineation of their underlying pathophysiological mechanisms is a major barrier to prevention and optimised treatments. Dysfunction of the 24-h circadian system is a candidate mechanism that has genetic, behavioural, and neurobiological links to mood syndromes. Here, we outline evidence for a new clinical phenotype, which we have called 'circadian depression'. We propose that key clinical characteristics of circadian depression include disrupted 24-h sleep-wake cycles, reduced motor activity, low subjective energy, and weight gain. The illness course includes early age-of-onset, phenomena suggestive of bipolarity (defined by bidirectional associations between objective motor and subjective energy/mood states), poor response to conventional antidepressant medications, and concurrent cardiometabolic and inflammatory disturbances. Identifying this phenotype could be clinically valuable, as circadian-targeted strategies show promise for reducing depressive symptoms and stabilising illness course. Further investigation of underlying circadian disturbances in mood syndromes is needed to evaluate the clinical utility of this phenotype and guide the optimal use of circadian-targeted interventions.

Association of treatment facets, severity of manic symptoms, psychomotor disturbances and psychotic features with response to electroconvulsive therapy in bipolar depression

OBJECTIVES

Clinically useful predictors of response to electroconvulsive therapy (ECT) are warranted, especially in the case of bipolar depression. The aim of this study was to explore the associations between response and its known and putative correlates.

METHODS

Six hundred seventy bipolar depressive patients treated with ECT were included in the study. The association between response (CGI-I ≤ 2) and mean seizure duration, number of treatments, age, sex, bipolar subtype, episode duration, HAM-D and YMRS scores, psychomotor disturbances and psychotic symptoms assessed through BPRS-EV were evaluated by means of univariate and multivariate logistic regression models, including quadratic and/or linear effects of continuous variables.

RESULTS

Four hundred eighty three patients (72%) were responders. Among known correlates of response, significant quadratic effects were found for seizure duration and number of treatments, while a linear association was confirmed for episode duration. Among putative correlates, severe motor retardation, tension or agitation, hyperactivity and delusions of guilt were significantly associated with response (p<.01) and a significant quadratic effect was found for YMRS score (p<.01).

CONCLUSION

Bipolar depressive patients with severe psychomotor disturbances, mood-congruent delusions and severe mixed features are highly responsive to ECT. A significant improvement in response prediction is expected when considering those clinical characteristics.

A symptom-based approach in predicting ECT outcome in depressed patients employing MADRS single items

Establishing symptom-based predictors of electroconvulsive therapy (ECT) outcome seems promising, however, findings concerning the predictive value of distinct depressive symptoms or subtypes are limited; previous factor-analytic approaches based on the Montgomery-Åsberg Depression Rating Scale (MADRS) remained inconclusive, as proposed factors varied across samples. In this naturalistic study, we refrained from these previous factor-analytic approaches and examined the predictive value of MADRS single items and their change during the course of ECT concerning ECT outcome. We used logistic and linear regression models to analyze MADRS data routinely assessed at three time points in 96 depressed psychiatric inpatients over the course of ECT. Mean age was 53 years (SD 14.79), gender ratio was 58:38 (F:M), baseline MADRS score was M = 30.20 (SD 5.42). MADRS single items were strong predictors of ECT response, remission and overall symptom reduction, especially items 1 (apparent sadness), 2 (reported sadness) and 8 (inability to feel), assessing affective symptoms. Strongest effects were found for regression models including item 2 (reported sadness) with up to 80% correct prediction of ECT outcome. ROC analyses were performed to estimate the optimal cut-point for treatment response. MADRS single items during the course of ECT might pose simple, reliable, time- and cost-effective predictors of ECT outcome. More severe affective symptoms of depression at baseline and a stronger reduction of these affective symptoms during the course of ECT seem to be positively associated with ECT outcome. Precise cut-off values for clinical use were proposed. Generally, these findings underline the benefits of a symptom-based approach in depression research and treatment in addition to depression sum-scores and generalized diagnoses.

Personality Disturbances in Melancholic and Nonmelancholic Unipolar Major Depression: A Systematic Review and Meta-Analysis

Although melancholic depression has been associated with a more adequate premorbid personality style, the empirical evidence supporting this statement is inconclusive. We conducted a systematic review and meta-analyzed studies comparing the presence of personality disturbances in melancholic and nonmelancholic subtypes of major depressive disorder (MDD). We defined a) a continuous outcome, defining personality traits as a dimensional construct, and b) a dichotomous outcome, defined as the presence/absence of personality disorders (PD). We also evaluated the role of potential moderators. Our results showed significantly higher levels of neuroticism and interpersonal sensitivity, and a higher likelihood of presenting a PD in nonmelancholic depression. No significant differences were found for extraversion. The scarcity of studies and high heterogeneity were among our limitations. In conclusion, personality disturbances seem to be overrepresented in nonmelancholic MDD. The assessment of personality disturbances can be useful in clinical practice and in the study of MDD heterogeneity.

When to consider electroconvulsive therapy (ECT)

OBJECTIVE

To familiarize the reader with the role of electroconvulsive therapy (ECT) in current psychiatric medicine.

METHOD

We review clinical indications for ECT, patient selection, contemporary ECT practice, maintenance treatment and ECT in major treatment guidelines.

RESULTS

ECT is underutilized largely due to persisting stigma and lack of knowledge about modern ECT technique.

CONCLUSION

ECT remains a vital treatment for patients with severe mood disorders, psychotic illness and catatonia.

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.

Subtypes of depression and their overlap in a naturalistic inpatient sample of major depressive disorder

Subtyping depression is important in order to further delineate biological causes of depressive syndromes. The aim of this study was to evaluate clinical and outcome characteristics of distinct subtypes of depression and to assess proportion and features of patients fulfilling criteria for more than one subtype. Melancholic, atypical and anxious subtypes of depression were assessed in a naturalistic sample of 833 inpatients using DSM-IV specifiers based on operationalized criteria. Baseline characteristics and outcome criteria at discharge were compared between distinct subtypes and their overlap. A substantial proportion of patients (16%) were classified with more than one subtype of depression, 28% were of the distinct anxious, 7% of the distinct atypical and 5% of the distinct melancholic subtype. Distinct melancholic patients had shortest duration of episode, highest baseline depression severity, but were more often early improvers; distinct anxious patients had higher NEO-Five Factor Inventory (NEO-FFI) neuroticism scores compared with patients with unspecific subtype. Melancholic patients with overlap of anxious features had worse treatment outcome compared to distinct melancholic and distinct anxious subtype. Distinct subtypes differed in only few variables and patients with overlap of depression subtypes may have independent clinical and outcome characteristics. Studies investigating biological causes of subtypes of depression should take influence of features of other subtypes into account.

Prediction of electroconvulsive therapy response and remission in major depression: meta-analysis

BACKGROUND

Electroconvulsive therapy (ECT) is considered to be the most effective treatment in severe major depression. The identification of reliable predictors of ECT response could contribute to a more targeted patient selection and consequently increased ECT response rates. Aims To investigate the predictive value of age, depression severity, psychotic and melancholic features for ECT response and remission in major depression.

METHOD

A meta-analysis was conducted according to the PRISMA statement. A literature search identified recent studies that reported on at least one of the potential predictors.

RESULTS

Of the 2193 articles screened, 34 have been included for meta-analysis. Presence of psychotic features is a predictor of ECT remission (odds ratio (OR) = 1.47, P = 0.001) and response (OR = 1.69, P < 0.001), as is older age (standardised mean difference (SMD) = 0.26 for remission and 0.35 for response (P < 0.001)). The severity of depression predicts response (SMD = 0.19, P = 0.001), but not remission. Data on melancholic symptoms were inconclusive.

CONCLUSIONS

ECT is particularly effective in patients with depression with psychotic features and in elderly people with depression. More research on both biological and clinical predictors is needed to further evaluate the position of ECT in treatment protocols for major depression. Declaration of interest None.

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.

Using patient self-reports to study heterogeneity of treatment effects in major depressive disorder

BACKGROUNDS

Clinicians need guidance to address the heterogeneity of treatment responses of patients with major depressive disorder (MDD). While prediction schemes based on symptom clustering and biomarkers have so far not yielded results of sufficient strength to inform clinical decision-making, prediction schemes based on big data predictive analytic models might be more practically useful.

METHOD

We review evidence suggesting that prediction equations based on symptoms and other easily-assessed clinical features found in previous research to predict MDD treatment outcomes might provide a foundation for developing predictive analytic clinical decision support models that could help clinicians select optimal (personalised) MDD treatments. These methods could also be useful in targeting patient subsamples for more expensive biomarker assessments.

RESULTS

Approximately two dozen baseline variables obtained from medical records or patient reports have been found repeatedly in MDD treatment trials to predict overall treatment outcomes (i.e., intervention v. control) or differential treatment outcomes (i.e., intervention A v. intervention B). Similar evidence has been found in observational studies of MDD persistence-severity. However, no treatment studies have yet attempted to develop treatment outcome equations using the full set of these predictors. Promising preliminary empirical results coupled with recent developments in statistical methodology suggest that models could be developed to provide useful clinical decision support in personalised treatment selection. These tools could also provide a strong foundation to increase statistical power in focused studies of biomarkers and MDD heterogeneity of treatment response in subsequent controlled trials.

CONCLUSIONS

Coordinated efforts are needed to develop a protocol for systematically collecting information about established predictors of heterogeneity of MDD treatment response in large observational treatment studies, applying and refining these models in subsequent pragmatic trials, carrying out pooled secondary analyses to extract the maximum amount of information from these coordinated studies, and using this information to focus future discovery efforts in the segment of the patient population in which continued uncertainty about treatment response exists.

Alteration of immune markers in a group of melancholic depressed patients and their response to electroconvulsive therapy

BACKGROUND

Immune system dysfunction is implicated in the pathophysiology of major depression, and is hypothesized to normalize with successful treatment. We aimed to investigate immune dysfunction in melancholic depression and its response to ECT.

METHODS

55 melancholic depressed patients and 26 controls participated. 33 patients (60%) were referred for ECT. Blood samples were taken at baseline, one hour after the first ECT session, and 48h after ECT series completion.

RESULTS

At baseline, melancholic depressed patients had significantly higher levels of the pro-inflammatory cytokine IL-6, and lower levels of the regulatory cytokine TGF-β than controls. A significant surge in IL-6 levels was observed one hour after the first ECT session, but neither IL-6 nor TGF-β levels normalized after completion of ECT series. Seventy per cent (n=23) of ECT recipients showed clinical response and 42% (n=10) reached remission. Neither IL-6 nor TGF-β changes correlated with clinical improvement following ECT. No significant changes in IL-10, TNF-α and CRP levels were found in relation to melancholia or response to ECT.

LIMITATIONS

As a naturalistic study, some potential confounders could not be eliminated or controlled, including medication use.

CONCLUSIONS

Melancholic depressed patients demonstrated a peripheral increase in IL-6 and reduction in TGF-β, which did not normalize despite clinical response to ECT. These findings may be consistent with emerging hypotheses of the role of inflammation in mediating neurotrophin expression. The implications of chronic inflammation in the melancholic depressed population for future medical health, particularly cardiovascular risk, are largely unknown and warrant further investigation.

Use of the Temperament and Character Inventory to Predict Response to Repetitive Transcranial Magnetic Stimulation for Major Depression

OBJECTIVE

The goal of this study was to investigate the utility of the Temperament and Character Inventory (TCI) in predicting antidepressant response to repetitive transcranial magnetic stimulation (rTMS).

BACKGROUND

Although rTMS of the dorsolateral prefrontal cortex is an established antidepressant treatment, little is known about predictors of response. The TCI measures multiple personality dimensions (harm avoidance, novelty seeking, reward dependence, persistence, self-directedness, self-transcendence, and cooperativeness), some of which have predicted response to pharmacotherapy and cognitive-behavioral therapy. A previous study suggested a possible association between self-directedness and response to rTMS in melancholic depression, although this was limited by the fact that melancholic depression is associated with a limited range of TCI profiles.

METHODS

Nineteen patients with a major depressive episode completed the TCI before a clinical course of rTMS over the dorsolateral prefrontal cortex. Treatment response was defined as ≥50% decrease in scores on the Hamilton Rating Scale for Depression (Ham-D). Baseline scores on each TCI dimension were compared between responders and nonresponders through analysis of variance. Pearson correlations were also calculated for temperament/character scores in comparison with percentage improvement in Ham-D scores.

RESULTS

Eleven of the 19 patients responded to rTMS. T-scores for persistence were significantly higher in responders than in nonresponders (P=0.022). Linear regression revealed a correlation between persistence scores and percentage improvement in Ham-D scores.

CONCLUSIONS

Higher persistence scores predicted antidepressant response to rTMS. This may be explained by rTMS-induced enhancement of cortical excitability, which has been found to be decreased in patients with high persistence. Personality assessment that includes measurement of TCI persistence may be a useful component of precision medicine initiatives in rTMS for depression.

Melancholic features in inpatients with major depressive disorder associate with differential clinical characteristics and treatment outcomes

To determine whether the presence of melancholic features in hospitalized patients with major depressive disorder (MDD) was associated with specific clinical characteristics and treatment outcomes, supporting melancholic depression as a distinct subtype within MDD. 126 acutely ill inpatients with MDD were enrolled in an open, 6-week trial with fixed-dose fluoxetine 20mg daily. Symptom severity was assessed regularly, using the 17-item Hamilton Depression Rating Scale (HAMD-17) and Clinical Global Impression of Severity (CGI-S). Melancholic features were defined according to the DSM-IV criteria. Clinical variables were compared between patients with and without melancholic features. Generalized estimating equations method was used to explore the differences in HAMD-17 and CGI-S scores between the 2 groups over time. Clinical response was defined as having a 50% or greater reduction in HAMD-17 scores. 96 (76.2%) of the 126 patients with at least one post-baseline assessment met the criteria for melancholic depression. Melancholic depression differed from non-melancholic depression in clinical characteristics and predicted a better response to fluoxetine treatment. The differentiation between melancholic and non-melancholic depression within MDD hence is clinically significant and valid.

Early improvement predicts outcome of major depressive patients treated with electroconvulsive therapy

The aim of this study was to test whether early symptom improvement predicts final response and remission for patients with major depressive disorder (MDD) receiving electroconvulsive therapy (ECT). MDD inpatients (N=130) requiring ECT were recruited. ECT was generally performed for a maximum of 12 sessions. Symptom severity was assessed using the 17-item Hamilton Depression Rating Scale (HAMD-17) before ECT, after every 3 ECT sessions, and after the last ECT. Early improvement was defined as a reduction in the HAMD-17 score by at least 20%, 25%, or 30% after 3 and 6 ECT sessions. Response was defined as 60% HAMD-17 score reduction, while remission was defined as an end point HAMD-17 score of ≦7. Receiver operating characteristic (ROC) curves were used to determine whether 3 or 6 ECT sessions had better discriminative capacity. Sensitivity, specificity and predictive values were calculated for the different definitions of early improvement. Of the 105 patients entering the analysis, 85.7% (n=90) and 70.5% (n=74) were classified as responders and remitters, respectively. Early improvement after 6 ECT sessions showed better discriminative capacity, with areas under the ROC curve at least 0.8. It had high sensitivity and high negative predictive value for all cutoffs in predicting response and remission. High response and remission rates were observed. Final response and remission could be predicted by early improvement after 6 ECT sessions. Patients without early improvement were unlikely to reach response and remission.

Baseline cognitive function does not predict the treatment outcome of electroconvulsive therapy (ECT) in late-life depression

BACKGROUND

No prior study has investigated whether impairment of specific cognitive functions at baseline may predict the short-term treatment outcome of electroconvulsive therapy (ECT) in elderly non-demented patients with major depression (MD).

METHODS

This longitudinal cohort study included 65 elderly patients with unipolar or bipolar MD, aged 60-85 years, treated with formula-based ECT. Treatment outcome was assessed using the 17-item Hamilton Rating Scale for Depression (HRSD17). Cognitive function at baseline was assessed using nine neuropsychological tests or subtests measuring information processing speed, verbal learning and memory, and aspects of executive function.

RESULTS

A poorer performance on the word reading task of the Color Word Interference Test rendered higher odds of achieving remission during the ECT course (p=0.021). Remission was defined as an HRSD17 score of 7 or less. There were no other significant associations between the treatment outcome of ECT and cognitive performance parameters assessed at baseline.

LIMITATIONS

The limited number of subjects may have reduced the generalizability of the findings. Multiple statistical tests increase the risk for making a type I error.

CONCLUSIONS

How well patients perform on neuropsychological tests at baseline is most likely not a predictor of, or otherwise not significantly associated with the treatment outcome of formula-based ECT in elderly patients with MD.

The effects of co-morbidity in defining major depression subtypes associated with long-term course and severity

BACKGROUND

Although variation in the long-term course of major depressive disorder (MDD) is not strongly predicted by existing symptom subtype distinctions, recent research suggests that prediction can be improved by using machine learning methods. However, it is not known whether these distinctions can be refined by added information about co-morbid conditions. The current report presents results on this question.

METHOD

Data came from 8261 respondents with lifetime DSM-IV MDD in the World Health Organization (WHO) World Mental Health (WMH) Surveys. Outcomes included four retrospectively reported measures of persistence/severity of course (years in episode; years in chronic episodes; hospitalization for MDD; disability due to MDD). Machine learning methods (regression tree analysis; lasso, ridge and elastic net penalized regression) followed by k-means cluster analysis were used to augment previously detected subtypes with information about prior co-morbidity to predict these outcomes.

RESULTS

Predicted values were strongly correlated across outcomes. Cluster analysis of predicted values found three clusters with consistently high, intermediate or low values. The high-risk cluster (32.4% of cases) accounted for 56.6-72.9% of high persistence, high chronicity, hospitalization and disability. This high-risk cluster had both higher sensitivity and likelihood ratio positive (LR+; relative proportions of cases in the high-risk cluster versus other clusters having the adverse outcomes) than in a parallel analysis that excluded measures of co-morbidity as predictors.

CONCLUSIONS

Although the results using the retrospective data reported here suggest that useful MDD subtyping distinctions can be made with machine learning and clustering across multiple indicators of illness persistence/severity, replication with prospective data is needed to confirm this preliminary conclusion.

Major depressive disorder subtypes to predict long-term course

BACKGROUND

Variation in the course of major depressive disorder (MDD) is not strongly predicted by existing subtype distinctions. A new subtyping approach is considered here.

METHODS

Two data mining techniques, ensemble recursive partitioning and Lasso generalized linear models (GLMs), followed by k-means cluster analysis are used to search for subtypes based on index episode symptoms predicting subsequent MDD course in the World Mental Health (WMH) surveys. The WMH surveys are community surveys in 16 countries. Lifetime DSM-IV MDD was reported by 8,261 respondents. Retrospectively reported outcomes included measures of persistence (number of years with an episode, number of years with an episode lasting most of the year) and severity (hospitalization for MDD, disability due to MDD).

RESULTS

Recursive partitioning found significant clusters defined by the conjunctions of early onset, suicidality, and anxiety (irritability, panic, nervousness-worry-anxiety) during the index episode. GLMs found additional associations involving a number of individual symptoms. Predicted values of the four outcomes were strongly correlated. Cluster analysis of these predicted values found three clusters having consistently high, intermediate, or low predicted scores across all outcomes. The high-risk cluster (30.0% of respondents) accounted for 52.9-69.7% of high persistence and severity, and it was most strongly predicted by index episode severe dysphoria, suicidality, anxiety, and early onset. A total symptom count, in comparison, was not a significant predictor.

CONCLUSIONS

Despite being based on retrospective reports, results suggest that useful MDD subtyping distinctions can be made using data mining methods. Further studies are needed to test and expand these results with prospective data.

What was learned: studies by the consortium for research in ECT (CORE) 1997-2011

OBJECTIVE

To review the findings of the four-hospital collaborative studies of electroconvulsive therapy (ECT) in unipolar depressed patients known as CORE between 1997 and 2011. Unipolar depressed patients were treated with bilateral ECT, and on remission were randomly assigned to a fixed schedule continuation ECT or to combined lithium and nortriptyline for 6 months. A second study compared three electrode placements in unipolar and bipolar depressed patients.

METHOD

Nineteen published reports were reviewed. The findings are compared with those of a parallel multi-hospital study of ECT led by a Columbia University Collaboration (CUC) team that studied right unilateral ECT in a similar population with similar inclusion/exclusion and remission criteria. Successful ECT was followed by placebo, nortriptyline alone, or combined lithium, and nortriptyline.

RESULTS

Relapse rates after remission were similar with fixed schedule ECT as with medications. Predictors of outcome (psychosis, suicide risk, polarity, melancholia, atypical depression, age) and technical aspects (electrode placement, seizure threshold, speed of response) are discussed,

CONCLUSION

The findings offer criteria to optimize the selection of patients, the technique, and outcome of ECT for unipolar and bipolar depressed patients. Continuation ECT is an effective alternative to continuation treatment with lithium and nortriptyline. Bilateral electrode placement is more efficient than alternative placements. ECT relieves both bipolar and unipolar depression.

Current electroconvulsive therapy practice and research in the geriatric population

Electroconvulsive therapy (ECT) is utilized worldwide for various severe and treatment-resistant psychiatric disorders. Research studies have shown that ECT is the most effective and rapid treatment available for elderly patients with depression, bipolar disorder and psychosis. For patients who suffer from intractable catatonia and neuroleptic malignant syndrome, ECT can be life saving. For elderly patients who cannot tolerate or respond poorly to medications and who are at a high risk for drug-induced toxicity or toxic drug interactions, ECT is the safest treatment option. Organic causes are frequently associated with late-life onset of neuropsychiatric conditions, such as parkinsonism, dementia and stroke. ECT has proven to be efficacious even when these conditions are present. During the next decade, research studies should focus on the use of ECT as a synergistic therapy, to enhance other biological and psychological treatments, and prevent symptom relapse and recurrence.

Electroconvulsive therapy: is there a role for treating older patients?

Electroconvulsive therapy (ECT) is a powerful acute treatment for severe and resistant depression. We review literature related to the efficacy, safety and tolerability of ECT in older people, with an emphasis on research studies and reviews published in the last 25 years. In general ECT has been considered a very effective and safe treatment for depression and other psychiatric and non-psychiatric disorders in older people. Amnesia is commonly attributed to ECT treatment, but studies suggest that the negative effects of ECT on cognition are probably small in older patients. Currently the balance of risks and benefits of ECT justify its use for severe depression in older patients, both with and without dementia.

Prevalence of psychotic symptoms in those with melancholic and nonmelancholic depression

The best classification of depressive disorders is still to be established. A melancholic subtype has a lengthy history, and recent research demonstrates its relevance. This study compares the prevalence of psychotic symptoms in nonmelancholic and melancholic depression and assesses whether there is a dimensional pattern in the severity of symptoms among the subtypes. Patients with unipolar depression were assessed for melancholic status, psychotic symptoms, and severity of depression. The diagnosis of melancholia was made by both Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), criteria and CORE measure. The DSM criteria assigned a much higher percentage of patients as melancholics (67.4%) than did the CORE (24.9%). Prevalence of psychosis was distinctly higher in the melancholics. Symptoms severity was higher among the melancholics when compared with the nonmelancholics. The presence of psychotic symptoms was not associated with an increase in the intensity of depressive symptoms. Psychotic symptoms are more frequently associated with the melancholic subtype of depression. This suggests clinical contiguity between the melancholic and psychotic subtypes and the clinical relevance of identifying melancholia.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders

OBJECTIVES

This 2013 update of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal has been to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. The guidelines are intended for use by all physicians seeing and treating patients with these conditions.

METHODS

The 2013 update was conducted by a systematic update literature search and appraisal. All recommendations were approved by the Guidelines Task Force.

RESULTS

This first part of the guidelines (Part 1) covers disease definition, classification, epidemiology, and course of unipolar depressive disorders, as well as the management of the acute and continuation phase treatment. It is primarily concerned with the biological treatment (including antidepressants, other psychopharmacological medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of adults.

CONCLUSIONS

To date, there is a variety of evidence-based antidepressant treatment options available. Nevertheless there is still a substantial proportion of patients not achieving full remission. In addition, somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated. Therefore, further high-quality informative randomized controlled trials are urgently needed.

Rediscovering catatonia: the biography of a treatable syndrome

OBJECTIVE

Catatonia, a disorder of movement and mood, was described and named in 1874. Other observers quickly made the same recognition. By the turn of the century, however, catatonia was incorporated as a type within a conjured syndrome of schizophrenia. There, catatonia has lain in the psychiatric classification for more than a century.

METHOD

We review the history of catatonia and its present status. In the 1970s, the tie was questioned when catatonia was recognized among those with mood disorders. The recognition of catatonia within the neuroleptic malignant syndrome offered effective treatments of high doses of benzodiazepines and electroconvulsive therapy (ECT), again questioning the tie. A verifying test for catatonia (the lorazepam sedation test) was developed. Soon the syndromes of delirious mania, toxic serotonin syndrome, and the repetitive behaviors in adolescents with autism were recognized as treatable variations of catatonia.

RESULTS

Ongoing studies now recognize catatonia among patients labeled as suffering from the Gilles de la Tourette's syndrome, anti-NMDAR encephalitis, obsessive-compulsive disease, and various mutisms.

CONCLUSION

Applying the treatments for catatonia to patients with these syndromes offers opportunities for clinical relief. Catatonia is a recognizable and effectively treatable neuropsychiatric syndrome. It has many faces. It warrants recognition outside schizophrenia in the psychiatric disease classification.

Predictors of response to ultrabrief right unilateral electroconvulsive therapy

BACKGROUND

Recent trials have demonstrated clinically meaningful efficacy and minimal cognitive side effects with ultrabrief pulsewidth right unilateral (RUL) ECT. In many countries it is gradually being adopted into clinical practice and further information on predictors of response is needed.

METHODS

Data collected from 75 depressed patients who received ultrabrief RUL ECT in a prospective research trial were analysed for predictors of response. Mood improvement was assessed with the Montgomery-Asberg Depression Rating Scale. Improvement in unipolar versus bipolar depression was analysed.

RESULTS

Sixty-one percent of patients met the criteria for response and 36% met the criteria for remission. Logistic regression identified index episode duration ≥one year (OR=10.50, p=.006), fewer failed antidepressant treatments (OR=0.46, p=.003), previous ECT course (OR=7.33, p=.01), and absence of concurrent antidepressant (OR=0.09, p=.005) as predictors of response. Psychotic features (OR=7.18, p=.032) and baseline depression severity (OR=0.90, p=.017) were predictors of remission. There was a trend towards greater improvement in bipolar than unipolar depression in the first week of treatment (p=0.077).

LIMITATIONS

Data were obtained from a prospective but non-randomised clinical trial which was designed to evaluate efficacy rather than to examine predictors of response. Treatment decisions (concurrent medication, switching to other types of ECT) were made on clinical grounds.

CONCLUSIONS

This preliminary study suggests that predictors of response for ultrabrief RUL ECT are similar to those identified for other types of ECT previously studied.

Psychomotor retardation in depression: biological underpinnings, measurement, and treatment

Psychomotor retardation is a long established component of depression that can have significant clinical and therapeutic implications for treatment. Due to its negative impact on overall function in depressed patients, we review its biological correlates, optimal methods of measurement, and relevance in the context of therapeutic interventions. The aim of the paper is to provide a synthesis of the literature on psychomotor retardation in depression with the goal of enhanced awareness for clinicians and researchers. Increased knowledge and understanding of psychomotor retardation in major depressive disorder may lead to further research and better informed diagnosis in regards to psychomotor retardation. Manifestations of psychomotor retardation include slowed speech, decreased movement, and impaired cognitive function. It is common in patients with melancholic depression and those with psychotic features. Biological correlates may include abnormalities in the basal ganglia and dopaminergic pathways. Neurophysiologic tools such as neuroimaging and transcranial magnetic stimulation may play a role in the study of this symptom in the future. At present, there are three objective scales to evaluate psychomotor retardation severity. Studies examining the impact of psychomotor retardation on clinical outcome have found differential results. However, available evidence suggests that depressed patients with psychomotor retardation may respond well to electroconvulsive therapy (ECT). Current literature regarding antidepressants is inconclusive, though tricyclic antidepressants may be considered for treatment of patients with psychomotor retardation. Future work examining this objective aspect of major depressive disorder (MDD) is essential. This could further elucidate the biological underpinnings of depression and optimize its treatment.

What we have learned about electroconvulsive therapy and its relevance for the practising psychiatrist

In this narrative review, the current knowledge base on the efficacy and the practice of electroconvulsive therapy (ECT) is reviewed, and its relevance for the practising psychiatrist is appreciated. In the past decade, several large-scale studies have confirmed the significant superiority of ECT in the treatment of severe and refractory psychiatric conditions, such as major depressive disorder and bipolar disorder. However, the efficacy of ECT is not reflected in current treatment algorithms, where ECT is often reserved as a last resort. However, clinical characteristics, such as the presence of psychotic symptoms, suicidality, or catatonic signs, should prompt the clinician to consider ECT earlier in the treatment course. ECT is a safe procedure, without absolute contraindications for its use. Nevertheless, patients' fears and complaints should be acknowledged, and patients should be adequately informed about expected benefits and possible risks, such as memory problems, that are generally transient. Research focusing on further minimizing memory problems, while maintaining a superior efficacy, is ongoing. Adequate continuation treatment, either pharmacotherapy or continuation ECT, after a successful ECT course is of vital importance to maintain the benefits achieved and should be the focus of future research.

The course of depressive symptoms in unipolar depressive disorder during electroconvulsive therapy: a latent class analysis

BACKGROUND

Research examining the course of depressive symptoms during electroconvulsive therapy (ECT) is relatively scarce.

OBJECTIVE

To classify patients according to the course of their depressive symptoms while receiving ECT.

METHODS

The sample consisted of 156 consecutive patients receiving ECT for unipolar depressive disorder. Depressive symptoms were measured weekly with the Montgomery-Asberg Depression Rating Scale. Latent class analysis was applied to identify distinct trajectories of symptom improvement.

RESULTS

We identified five classes of different trajectories (improvement rates) of depressive symptoms, i.e. fast improvement (39 patients), intermediate improvement (47 patients), slow improvement (30 patients), slow improvement with delayed onset (18 patients), and finally a trajectory with no improvement (20 patients). The course of depressive symptoms at the end of the treatment within the trajectories of intermediate improvement, slow improvement and slow improvement with delayed onset, was still improving and did not achieve a plateau.

CONCLUSION

The different courses of depressive symptoms during ECT probably contribute to mixed results of prediction studies of ECT outcome. Data suggest that for a large group of patients no optimal clinical endpoint can be identified, other than full remission or no improvement at all, to discontinue ECT.

Melancholic symptoms as assessed by the Hamilton Depression Rating Scale and outcomes with and without electroconvulsive therapy on an in-patient mood disorders unit

Rasmussen KG, Stevens SR, Kung S, Mohan A. Melancholic symptoms as assessed by the Hamilton Depression Rating Scale and outcomes with and without electroconvulsive therapy on an in-patient mood disorders unit.

BACKGROUND

We investigated whether 24-item Hamilton Rating Scale for Depression (HamD24)-based melancholia ratings correlated with treatment outcome, with special focus on whether electroconvulsive therapy (ECT) was used in depressed patients treated on an in-patient mood disorders unit.

METHODS

We analysed the data on ECT- versus non-ECT-treated patients' outcomes relative to melancholia subscale scores. Two HamD24-based melancholia rating scale scores were computed for 201 depressed in-patients at admission and discharge. Baseline melancholia ratings were analysed to see if they correlated with improvement in total HamD24 scores. We also tested to see if the melancholia subscales followed unimodal or bimodal distributions.

RESULTS

Melancholic symptoms as assessed by one of the HamD24-based subscales directly correlated with overall improvement. Although ECT treatment was associated with greater improvement than was noted in non-ECT-treated patients, severity of melancholia ratings did not affect this relationship. Finally, both melancholia subscale scores followed approximately unimodal distributions.

CONCLUSIONS

HamD24-based methods to assess severity of melancholic symptoms have limited clinical utility on an in-patient mood disorders unit in general, and for predicting ECT response in particular. Furthermore, these methods do not seem to identify bimodal populations of depressed patients (i.e. melancholic vs. non-melancholic).

Seizure threshold in a large sample: implications for stimulus dosing strategies in bilateral electroconvulsive therapy: a report from CORE

OBJECTIVE

We sought to examine the relationship of seizure threshold (ST) to age and other demographic characteristics in a large sample where ST was determined by the dose titration (DT) method. We also compared the resulting stimulation levels to estimates predicted by an age-based formula, the half-age (HA) method.

METHODS

In a multicenter prospective study, patients received a standardized course of bilateral electroconvulsive therapy for major depression using a brief pulse device. The ST was determined at the first treatment using a fixed algorithm of stimulations. Subsequent seizures were induced at a level 50% higher than the empirically determined ST. We only included data from subjects receiving methohexital anesthesia. We correlated ST with demographic and clinical characteristics of the sample. The actual dosing levels at the second treatment were compared with estimates based on HA.

RESULTS

Of the original 531 subjects, 402 met criteria for the current analysis. The ST was positively correlated with age. Male patients had slightly higher ST than female patients. Neither race, severity of illness, psychosis, nor use of psychotropic medications affected ST. Little variability in titrated ST was observed among our patients. An ST of 40 ("percent of charge") or lower was found in 97.5% of patients, with either 20 or 40 in 80% of patients. Ninety-six percent of the patients were treated at the 3 levels of 15%, 30%, or 60%. Estimated HA stimulus levels offered a wider range of choices compared with this particular algorithm used for ST determination at an average level of 18% above the determined ST.

CONCLUSIONS

Seizure threshold correlates strongly with age, whereas there is a weaker relation between ST and sex. There was little individual variation of ST determined by the DT method among subjects, possibly because of the wide spacing between steps of this particular titration algorithm. Half-age estimates were 18% above the empirically determined ST. This suggests that the use of the HA estimates at the first treatment may result in fewer stimulations compared with the DT method.

Antidepressant electroconvulsive therapy: mechanism of action, recent advances and limitations

A considerable number of depressive patients do not respond to or remit during pharmacotherapeutical or psychotherapeutical interventions resulting in an increasing interest in non-pharmacological strategies to treat affective disorders. Electroconvulsive therapy (ECT) dates back to the beginning of modern biologic psychiatry and ongoing research has successfully improved efficacy in addition to safety while reducing side effects. Double-blind, randomized, controlled trials have shown powerful interactions between electrode placement (right unilateral, bifrontal, bitemporal) and dosage (relative to seizure threshold) in the efficacy and side effects of ECT. This review aims to summarize current research data on the mechanism of action, efficacy, and recent advances in ECT technique.

Change in seizure threshold during electroconvulsive therapy

The seizure threshold (ST) is a measure of the minimum electrical energy necessary to induce a grand mal seizure. Dose titration of the ST has been suggested to optimize stimulus dosing in electroconvulsive therapy (ECT). The change in ST with remission is examined in a large sample of unipolar depressed patients.

METHODS

In a study of continuation treatments after successful ECT, the ST was determined at the first treatment and again 1 week after remission using a conventional ST measurement protocol. Patients were treated with bilateral electrode placement at 150% above the measured ST.

RESULTS

In 80 subjects, the ST measured the same in 70%, increased in 21%, and decreased in 9% at remission.

CONCLUSIONS

In a study of bilateral ECT, the ST did not rise conclusively with remission.