ECT use in unipolar and bipolar depression

Elderly Bipolar Disorder

PURPOSE OF REVIEW

With more individuals reaching older ages, bipolar disorder is no longer a rare illness in the elderly. Despite the growing number of the older individuals with the illness, there are few studies that focus on bipolar disorder in the geriatric population leading to gaps in clinical knowledge and treatment. The aim of this study is therefore to increase understanding by summarizing the available literature on the epidemiology, symptomatology, comorbidities, and treatment recommendations in this cohort, as well as to suggest areas for future clinical and research focus.

RECENT FINDINGS

The prevalence of bipolar disorder is underestimated in the geriatric population. The illness maintains the main features observed in the other cohorts but it also has some specific characteristics in the older individuals. In this cohort, psychiatric and medical comorbidities tend to be the rule rather than the exception. Higher rates of cognitive impairments than age- and education-matched groups present across all of the illness phases. Treatment is more challenging in the elderly individuals due to higher rates of comorbidities and susceptibility to medication side effects. Two cohorts of older individuals with bipolar disorder can be recognized, those with symptoms that start earlier in life and those with late-life onset. Although the knowledge about elderly bipolar disorder is only slowly growing, it is increasingly recognized as an illness with unique features. More work is needed to improve diagnosis and to establish treatment guidelines.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Depression, mitochondrial bioenergetics, and electroconvulsive therapy: a new approach towards personalized medicine in psychiatric treatment - a short review and current perspective

Major depressive disorder (MDD) is a globally occurring phenomenon and developed into a severe socio-economic challenge. Despite decades of research, the underlying pathophysiological processes of MDD remain incompletely resolved. Like other mental disorders, MDD is hypothesized to mainly affect the central nervous system (CNS). An increasing body of research indicates MDD to also change somatic functioning, which impairs the physiological performance of the whole organism. As a consequence, a paradigm shift seems reasonable towards a systemic view of how MDD affects the body. The same applies to treatment strategies, which mainly focus on the CNS. One new approach highlights changes in the bioenergetic supply and intracellular network dynamics of mitochondria for the pathophysiological understanding of MDD. Mitochondria, organelles of mostly all eukaryotic cells, use carbon compounds to provide biochemical energy in terms of adenosine triphosphate (ATP). ATP is the bioenergetic currency and the main driver for enzymatic activity in all cells and tissues. Clinical symptoms of MDD including fatigue, difficulties concentrating, and lack of motivation were reported to be associated with impaired mitochondrial ATP production and changes in the density of the mitochondrial network. Additionally, the severity of these symptoms correlates negatively with mitochondrial functioning. Psychotherapy, antidepressant medication, and electroconvulsive therapy (ECT), a method used to treat severe and treatment-resistant forms of MDD, achieve robust antidepressant effects. The biological mechanisms beyond the treatment response to antidepressant strategies are partially understood. Here, mitochondrial functioning is discussed as a promising new biomarker for diagnosis and treatment effects in MDD.

Number of Electroconvulsive Therapy Sessions required for Thai Psychiatric Patients: a Retrospective Study

OBJECTIVE

To study predictors of the number of electroconvulsive therapy (ECT) sessions required for symptom remission in psychiatric patients.

PATIENTS AND METHODS

We conducted chart reviews for 95 patients whose condition remitted following inpatient ECT. We analyzed the clinical characteristics of the patients and compared the number of ECT sessions between adult (age 18-59 years) and elderly (age ≥ 60 years) patients.

RESULTS

The overall mean ± SD of the number of ECT sessions was 11.8 ± 4.7 (range: 6-24). By diagnosis, it was 13.3 ± 5.5 for individuals with schizophrenia, 10.1 ± 2.7 for schizoaffective disorder, 14.4 ± 5.6 for bipolar depression, 9.4 ± 1.9 for bipolar mania, 10.9 ± 4.3 for major depressive disorder (MDD), and 11.8 ± 4.3 for those with other diagnoses. For MDD, the number of ECT sessions in elderly patients (13.4 ± 4.6) was statistically greater than that in adult patients (9 ± 2.9) (p = 0.008).

CONCLUSION

The number of ECT sessions varied by age and diagnosis. The number of ECT sessions in elderly MDD patients was higher than that in adult MDD patients.

ECT beyond unipolar major depression: systematic review and meta-analysis of electroconvulsive therapy in bipolar depression

OBJECTIVE

In this systematic review and meta-analysis, the response, remission, and speed of response in adults with major depressive disorder (MDD) and bipolar disorder in depressive episode (BDD) receiving an acute course of electroconvulsive therapy (ECT) were quantitatively analyzed.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, 1660 citations were identified through five electronic databases. Nineteen articles met final inclusion criteria for meta-analysis.

RESULTS

The pooled response and remission rates with ECT in MDD were 74.2% (n = 1246/1680) and 52.3% (n = 850/1626), respectively. In BDD, they were 77.1% (n = 437/567) and 52.3% (n = 275/377), respectively. Although response rates to ECT were statistically higher in BDD (OR = 0.73, 95% CI: 0.56-0.95, P = 0.02), remission rates were similar (OR = 0.91, 95% CI: 0.65-1.26, P = 0.56). Individuals with BDD vs. MDD required fewer number of ECT sessions to achieve response (SMD = -0.23, 95% CI: -0.44 to -0.023, P = 0.03). There were no significant moderator effects identified.

CONCLUSION

Response rates and speed of response are higher in individuals with BDD; however, remission rates are equivalent. These findings support increased utilization of ECT in individuals with treatment-refractory BDD.

Speed of antidepressant response to electroconvulsive therapy in bipolar disorder vs. major depressive disorder

AIMS

We reviewed studies that reported speed of antidepressant response to electroconvulsive therapy (ECT) in both bipolar depression (BPD) and major depressive disorder (MDD).

METHODS

We identified English language reports allowing this comparison.

RESULTS

Ten studies met our criteria. Four reported significantly faster response in BPD and in one there was trend for faster response. None reported evidence for slower response in BPD.

CONCLUSION

The findings support further study of speed of response to ECT in BPD.

Brain stimulation treatments in bipolar disorder: A review of the current literature

OBJECTIVES

Brain stimulation techniques are non-pharmacologic strategies which offer additional therapeutic options for treatment-resistant depression (TRD). The purpose of this paper is to review the current literature regarding the use of brain stimulation in resistant bipolar disorder (BD), with particular reference to hypomanic/manic symptoms.

METHODS

Keywords pertaining to the brain simulation techniques used in the treatment of depression (either unipolar or bipolar) along with their role in regard to hypomanic/manic symptoms were used to conduct an electronic search of the literature. Pertinent findings were identified by the authors and reviewed.

RESULTS

Brain stimulation techniques represent a valid therapeutic option in TRD. They have been extensively studied in unipolar depression and, to a minor extent, in the depressive phase of BD, showing encouraging but often limited results. With exception of electroconvulsive therapy, the efficacy of brain stimulation in the treatment of manic symptoms of bipolar patients is still uncertain and needs to be fully evaluated.

CONCLUSIONS

Brain stimulation in BD is derived from its use in unipolar depression. However, there are many important differences between these two disorders and more studies with a systematic approach need to be conducted on larger samples of bipolar patients with treatment-resistant characteristics.

A long-term follow-up of clinical response and regional cerebral blood flow changes in depressed patients treated with ECT

BACKGROUND

Depression is the leading cause of disability worldwide and electroconvulsive therapy (ECT) is the most potent therapy. We investigated the clinical response and regional cerebral blood flow changes in depressed in patients treated with (ECT) in a repeated longitudinal study.

METHOD

Forty-nine patients (21 men and 28 women) with a mean age 61 years underwent ECT. Forty-one patients grading improvement after the initial ECT-series (responder group) were compared with eight, grading no improvement (non-responder group). The patients underwent neuropsychiatric ratings, measure of clinical response (defined as ≥50% reduction of pre-treatment depression score) and measure of regional cerebral blood flow (rCBF).

RESULTS

The responder group had an initial 60-82%, and the non-responder group a 30-64% clinical response throughout the follow-up. The non-responder group showed more reported depression (p=.003), and vegetative anxiety (p=.024), with a generally higher left temporal rCBF (p=.045).

LIMITATIONS

The retrospective approach and the small sample-size.

CONCLUSION

Patients with no subjective improvement after ECT had lesser objective clinical response, more sustained reported depression with anxiety features, and higher left temporal rCBF.

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.