Relapse prevention by means of paroxetine in ECT-treated patients with major depression: a comparison with imipramine and placebo in medium-term continuation therapy

The influence of concomitant antidepressant and antipsychotic medication on antidepressant effect and seizure duration of electroconvulsive therapy

Background

A significant proportion of patients with a depressive disorder show resistance to pharmacological and psychotherapeutic antidepressant treatments. Electroconvulsive therapy (ECT) is still one of the most effective treatment methods, especially in the acute phase. In everyday clinical practice, this usually accompanies pharmacological treatment. It has been shown that pharmacological treatment following acute ECT treatment reduces the rate of relapses. However, the effect of various antidepressants (ADs) and antipsychotics (APs) on the effect during the course of ECT has rarely been investigated.

Methods

In this retrospective chart review study, the data of 104 depressive patients treated with ECT were examined. We analyzed the influence of concomitant administration of AD and AP or no psychotropic medication on the effect of ECT using the Montgomery-Åsberg Depression Rating Scale (MADRS). We further analyzed the influence of the ADs Bupropion, Venlafaxine, and Sertraline or no AD and the influence of augmentation with Aripiprazole or Quetiapine or Olanzapine.

Results/discussion

Psychotropic medication did not have an impact on antidepressant efficacy of ECT as measured with the MADRS scores. In addition, the comparison between the antidepressant or antipsychotic medications themselves did not show any significant difference. However, we found a significantly different seizure duration depending on the antidepressant substance that patients received during ECT (p = .008). ECT treatment itself led to a highly significant reduction of 13.3 points in the MADRS (p <.001).

Conclusion

Taken together, our study underlines that concomitant psychotropic medication while doing electroconvulsive therapy does not bare the risk of prolonged seizure duration or does it reduce the effectiveness of ECT. To the best of our knowledge, this study is the first to examine the effect of treatment with antidepressants in combination with antipsychotics while doing ECT. In light of our results, this combination therapy is safe and effective. Bearing in mind the delay in onset of antidepressant action of medication and the importance of antidepressant medication for relapse prevention, this study further supports the recommendation that psychotropic medication should be given in adjunction to ECT.

Irving Kirsch opens a window on antidepressant medications

When it comes to antidepressant medications - popular, backbone drugs of modern psychiatry - even learned scholars and savvy clinicians find it difficult to separate honest, rigorous research from that which thrives on hidden agendas and ulterior motives. Fortunately, a mounting corpus of data-based studies, mostly meta-analyses, casts new and critical light on the clinical efficacy, side effects, and therapeutic outcomes of antidepressants. Spearheading these efforts over the past few decades, Irving Kirsch and colleagues have challenged the hegemonic view of antidepressants as an effective therapeutic intervention. Notably, Kirsch illuminates the small difference between antidepressants and placebos in mitigating depression-a difference that may be statistically significant yet fails to reach clinical significance. This piece sketches the important contributions Kirsch has made to the scientific understanding of antidepressant medications.

Influence of adjuvant nortriptyline on the efficacy of electroconvulsive therapy: A randomized controlled trial and 1-year follow-up

OBJECTIVE

There is limited evidence that adding an antidepressant to electroconvulsive therapy (ECT), compared with ECT monotherapy, improves outcomes. We aimed to determine whether the addition of nortriptyline to ECT enhances its efficacy and prevents post-ECT relapse.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial (RCT). Patients with major depressive disorder and an indication for ECT received either nortriptyline or placebo during a bilateral ECT course. Outcome measures were mean decrease in Hamilton Rating Scale for Depression (HRSD) score, response, remission, and time to response and remission. Patients who attained remission participated in a 1-year follow-up study with open-label nortriptyline. Outcome measures were relapse and time to relapse.

RESULTS

We included 47 patients in the RCT. In the nortriptyline group, 83% showed response, 74% attained remission, and the mean decrease in HRSD score was 21.6 points. In the placebo group these figures were, respectively, 81% (p = 0.945), 73% (p = 0.928) and 20.7 points (p = 0.748). Thirty-one patients participated in the follow-up study. In patients who had received nortriptyline during the RCT, 47% relapsed at a mean of 34.2 weeks. Patients who had received placebo showed similar treatment results. In both study phases, no statistically significant differences between the nortriptyline and the placebo group were found.

CONCLUSION

In our sample of severely depressed patients who were often medication resistant and suffering from psychotic depression, the addition of nortriptyline to ECT did not enhance its efficacy or prevent post-ECT relapse. Encouragingly, even in these patients ECT was highly effective and relapse rates were relatively low.

Influence of an adjuvant antidepressant on the efficacy of electroconvulsive therapy: A systematic review and meta-analysis

OBJECTIVE

The primary indication for electroconvulsive therapy is medication-resistant major depression. There is some evidence that combining electroconvulsive therapy with an antidepressant, instead of electroconvulsive therapy monotherapy, might improve remission rates. However, data on this topic have not been systematically studied. We undertook a systematic review and meta-analysis to determine the effectiveness of an adjuvant antidepressant during electroconvulsive therapy for major depression.

METHODS

Embase, Medline Ovid, Web of Science, Cochrane Central, PsychINFO Ovid and Google Scholar were searched up to January 2019. Randomized controlled trials and cohort studies reporting on the influence of an adjuvant antidepressant on the efficacy of electroconvulsive therapy for major depression were included. Authors independently screened records, extracted data and assessed study quality. We reported this systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Nine studies were included in the meta-analysis. The meta-analysis revealed a significant advantage of adjuvant antidepressants versus placebo. The overall effect size per category of antidepressant was as follows: tricyclic antidepressants: Hedges' g 0.32 (95% confidence interval: [0.14, 0.51]) (k = 6) with low heterogeneity (I2: 4%, p = 0.39); selective serotonin reuptake inhibitors/serotonin noradrenaline reuptake inhibitors: Hedges' g 0.27 (95% confidence interval: [0.03, 0.52]) (k = 2) with a lack of heterogeneity (I2: 0%, p = 0.89); and monoamine oxidase inhibitors: Hedges' g 0.35 (95% confidence interval: [-0.07, 0.77]) with moderate heterogeneity (I2: 43%, p = 0.17) (k = 3).

CONCLUSION

An adjuvant antidepressant enhances the efficacy of electroconvulsive therapy for major depression. Tricyclic antidepressants, selective serotonin reuptake inhibitors/serotonin noradrenaline reuptake inhibitors and monoamine oxidase inhibitors showed the same effect size. However, the effect sizes of tricyclic antidepressants and monoamine oxidase inhibitors are most likely underestimated, due to insufficient doses in most of the included studies. We recommend the routine use of an adequately dosed antidepressant during electroconvulsive therapy for major depression.

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.

The Efficacy and Safety of Concomitant Psychotropic Medication and Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is an effective treatment for severe psychiatric disorders. Patients referred to ECT are often taking multiple medications, many of which can potentially affect the safety and efficacy of their course of ECT. This review evaluates the impact of a variety of psychotropic medications often used in conjunction with ECT and examines strategies to optimize their management. The review encompasses mood stabilizers, antidepressants, benzodiazepines, antiepileptics, antipsychotics, and other commonly used psychotropics.

Concurrent Electroconvulsive Therapy and Bupropion Treatment

BACKGROUND

Bupropion is associated with a dose-dependent increased risk of seizures. Use of concomitant bupropion and electroconvulsive therapy (ECT) remains controversial because of an increased risk of prolonged seizures. This is the first systematic evaluation of the effect of bupropion on ECT.

METHODS

A case group (n = 119), patients treated with concomitant ECT and bupropion, was compared with an age and gender frequency-matched control group (n = 261), treated with only ECT. Electroconvulsive therapy treatment data including seizure length, number of treatments, and concurrent medications were extracted. Longitudinal mixed models examined ECT versus ECT + bupropion group differences over the course of treatments measured by seizure duration (electroencephalogram [EEG] and motor). Multivariable models examined the total number of treatments and first and last seizure duration. All models considered group differences with ECT treatment measures adjusted for age, gender, benzodiazepine treatment, lead placement, and setting.

RESULTS

Electroconvulsive therapy treatment with bupropion led to shorter motor seizure duration (0.047) and EEG seizure duration (P = 0.001). The number of ECT treatments (7.3 vs 7.0 treatments; P = 0.23), respectively, or the probability of a prolonged seizure (P = 0.15) was not significantly different. Benzodiazepine use was significantly more common in control subjects (P = 0.01).

LIMITATIONS

This is a retrospective analysis limited in part by unavailable variables (seizure threshold, nature of EEG and motor seizure monitoring, type of ECT device, dosing and formulation of bupropion, and duration of the current depressive illness).

CONCLUSIONS

This study revealed a significantly shorter duration in seizure length with ECT + concomitant bupropion, but not in the number of required treatments in those treated compared with ECT without bupropion. There remains a critical need to reevaluate the efficacy of concomitant use of psychotropic medications + ECT.

Factors Related to the Changes in Quality of Life for Patients With Depression After an Acute Course of Electroconvulsive Therapy

OBJECTIVE

The aim of this study was to examine the effect of electroconvulsive therapy (ECT) on quality of life (QOL), depressive symptoms, and functioning for patients with depression, and to explore the variables related to QOL changes.

METHODS

Ninety-five inpatients with depression receiving at least 6 ECT sessions and completed all measures were included. Quality of life, symptom severity, and functioning were assessed using Short Form 36 (SF-36), the 17-item Hamilton Rating Scale for Depression (HAMD-17), and the Modified Work and Social Adjustment Scale (MWSAS), before and after ECT. The SF-36 includes 8 subscales, physical component summary (PCS), and mental component summary (MCS). Adverse effects after ECT, including headache, muscle pain, and nausea/vomiting, were also recorded.

RESULTS

All 8 SF-36 subscales, PCS, MCS, HAMD-17, and MWSAS improved significantly after treatment. Using multiple linear regression analysis, MWSAS changes predicted PCS changes significantly after adjusting for baseline PCS. Similarly, using multiple linear regression analysis, MWSAS changes were significant variables associated with MCS changes after adjusting for ECT frequency, HAMD-17 changes, and baseline MCS. The ECT improved QOL, depressive symptoms, and functioning.

CONCLUSIONS

Whether strategies to enhance functioning during an acute course of ECT could improve QOL is needed to be examined in a further study.

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.

Key updates in the clinical application of electroconvulsive therapy

ECT is the oldest and most effective therapy available for the treatment of severe major depression. It is highly effective in individuals with treatment resistance and when a rapid response is required. However, ECT is associated with memory impairment that is the most concerning side-effect of the treatment, substantially contributing to the controversy and stigmatization surrounding this highly effective treatment. There is overwhelming evidence for the efficacy and safety of an acute course of ECT for the treatment of a severe major depressive episode, as reflected by the recent FDA advisory panel recommendation to reclassify ECT devices from Class III to the lower risk category Class II. However, its application for other indications remains controversial, despite strong evidence to the contrary. This article reviews the indication of ECT for major depression, as well as for other conditions, including catatonia, mania, and acute episodes of schizophrenia. This study also reviews the growing evidence supporting the use of maintenance ECT to prevent relapse after an acute successful course of treatment. Although ECT is administered uncommonly to patients under the age of 18, the evidence supporting its use is also reviewed in this patient population. Finally, memory loss associated with ECT and efforts at more effectively monitoring and reducing it are reviewed.

Possible Synergy Between Electroconvulsive Therapy and Imipramine: A Case Report

This report describes a 63-year-old woman, who had experienced 3 previous episodes of severe major depressive disorder. The first 2 episodes responded to treatment with antidepressants, whereas the third episode was accompanied by psychotic features and responded well to treatment with electroconvulsive therapy (ECT). After a severe relapse, the patient responded very slowly to a second course of ECT and failed to achieve full remission. Within a few weeks, she had another severe relapse and responded very rapidly to a combination of ECT and imipramine. The possible enhancement of the antidepressant efficacy of ECT by combining it with a tricyclic antidepressant (TCA) has received little study, although the literature provides some evidence for a synergy between ECT and TCAs. Combining ECT with a TCA may be a useful strategy in patients who fail to achieve full remission or who experience a rapid relapse.

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.

Rating scales measuring the severity of psychotic depression

OBJECTIVE

Unipolar psychotic depression (PD) is a severe and debilitating syndrome, which requires intensive monitoring. The objective of this study was to provide an overview of the rating scales used to assess illness severity in PD.

METHOD

Selective review of publications reporting results on non-self-rated, symptom-based rating scales utilized to measure symptom severity in PD. The clinical and psychometric validity of the identified rating scales was reviewed.

RESULTS

A total of 14 rating scales meeting the predefined criteria were included in the review. These scales grouped into the following categories: (i) rating scales predominantly covering depressive symptoms, (ii) rating scales predominantly covering psychotic symptoms, (iii) rating scales covering delusions, and (iv) rating scales covering PD. For the vast majority of the scales, the clinical and psychometric validity had not been tested empirically. The only exception from this general tendency was the 11-item Psychotic Depression Assessment Scale (PDAS), which was developed specifically to assess the severity of PD.

CONCLUSION

In PD, the PDAS represents the only empirically derived rating scale for the measurement of overall severity of illness. The PDAS should be considered in future studies of PD and in clinical practice.

Prevention of Relapse and Recurrence in Adults with Major Depressive Disorder: Systematic Review and Meta-Analyses of Controlled Trials

BACKGROUND

Findings of substantial remaining morbidity in treated major depressive disorder (MDD) led us to review controlled trials of treatments aimed at preventing early relapses or later recurrences in adults diagnosed with MDD to summarize available data and to guide further research.

METHODS

Reports (n = 97) were identified through systematic, computerized literature searching up to February 2015. Treatment versus control outcomes were summarized by random-effects meta-analyses.

RESULTS

In 45 reports of 72 trials (n = 14 450 subjects) lasting 33.4 weeks, antidepressants were more effective than placebos in preventing relapses (response rates [RR] = 1.90, confidence interval [CI]: 1.73-2.08; NNT = 4.4; p < 0.0001). In 35 reports of 37 trials (n = 7253) lasting 27.0 months, antidepressants were effective in preventing recurrences (RR = 2.03, CI 1.80-2.28; NNT = 3.8; p < 0.0001), with minor differences among drug types. In 17 reports of 22 trials (n = 1 969) lasting 23.7 months, psychosocial interventions yielded inconsistent or inconclusive results.

CONCLUSIONS

Despite evidence of the efficacy of drug treatment compared to placebos or other controls, the findings further underscore the substantial, unresolved morbidity in treated MDD patients and strongly encourage further evaluations of specific, improved individual and combination therapies (pharmacological and psychological) conducted over longer times, as well as identifying clinical predictors of positive or unfavorable responses and of intolerability of long-term treatments in MDD.

A 2-year follow-up study of patients participating in our transcranial pulsating electromagnetic fields augmentation in treatment-resistant depression

OBJECTIVE

We have made a 2-year follow-up study to evaluate the effect of repeated transcranial pulsating electromagnetic fields (T-PEMF) augmentation in patients who had achieved remission but later on relapsed, as well as to identify factors contributing to treatment-resistant depression in patients who did not respond to T-PEMF.

METHODS

Using the Longitudinal Expert Assessment of All Data approach the patients were classified in four groups: A: patients who achieved remission; B: patients with doubtful effect; C: patients with no effect; and D: patients who were hard-to-assess.

RESULTS

In group A, comprising 27 patients, 13 had relapsed; they obtained a clear remission after a repeated course of T-PEMF augmentation. In group D, comprising 16 patients, we identified misdiagnostic factors both concerning the event of remission after the previous T-PEMF augmentation and concerning the aetiology (psychosocial stressors and co-morbid conditions). Compared with the other groups, the group D patients had a smaller number of previous episodes (p=0.09) and a longer duration of the current episode (p=0.01).

CONCLUSION

T-PEMF has an effect among patients who relapsed after remission with the first series of T-PEMF. Treatment-resistant depression is a condition that has a high degree of multivariate problems. Misuse of alcohol or drugs, severe somatic disorders and other psychosocial problems may need other kinds of treatment before T-PEMF augmentation.

Psychometric analysis of the Melancholia Scale in trials with non-pharmacological augmentation of patients with therapy-resistant depression

OBJECTIVE

The Melancholia Scale (MES) consists of the psychic core items of the Hamilton Depression Scale (HAM-D6) (depressed mood, interests, psychic anxiety, general somatic, guilt feelings, and psychomotor retardation) and the neuropsychiatric items of the Cronholm-Ottossen Depression Scale. Patients resistant to anti-depressant medication (therapy-resistant depression) have participated in our trials with non-pharmacological augmentation. On the basis of these trials, we have evaluated to what extent the neuropsychiatric subscale of the MES (concentration difficulties, fatigability, emotional introversion, sleep problems, and decreased verbal communication) is a measure of severity of apathia when compared with the HAM-D6 subscale of the MES.

METHODS

We have focused on rating sessions at baseline (week 0) and after 2 and 4 weeks of therapy in four clinical trials on therapy-resistant depression with the following augmentations: electroconvulsive therapy, bright light therapy, transcranial magnetic stimulation or pulsed electromagnetic fields, and wake therapy. The item response theory model constructed by Mokken has been used as the psychometric validation of unidimensionality. For the numerical evaluation of transferability, we have tested item ranks across the rating weeks.

RESULTS

In the Mokken analysis, the coefficient of homogeneity was above 0.40 for both the HAM-D subscale and the apathia subscale at week 4. The numerical transferability across the weeks was statistically significant (p < 0.05) for both subscales.

CONCLUSION

The apathia subscale is a unidimensional scale with acceptable transferability for the measurement of treatment-resistant symptoms, analogue to the psychic core subscale (HAM-D6).

Relapse following successful electroconvulsive therapy for major depression: a meta-analysis

High rates of early relapse following electroconvulsive therapy (ECT) are typically reported in the literature. Current treatment guidelines offer little information to clinicians on the optimal nature of maintenance therapy following ECT. The aim of this study was to provide a systematic overview of the existing evidence regarding post-ECT relapse. A keyword search of electronic databases was performed for studies appearing in the peer-reviewed literature before January 2013 reporting on relapse rates in responders to an acute course of ECT administered for a major depressive episode. Meta-analyses were performed where appropriate. Thirty-two studies with up to 2 years' duration of follow-up were included. In modern era studies of continuation pharmacotherapy, 51.1% (95% CI=44.7-57.4%) of patients relapsed by 12 months following successful initial treatment with ECT, with the majority (37.7%, 95% CI=30.7-45.2%) relapsing within the first 6 months. The 6-month relapse rate was similar in patients treated with continuation ECT (37.2%, 95% CI=23.4-53.5%). In randomized controlled trials, antidepressant medication halved the risk of relapse compared with placebo in the first 6 months (risk ratio=0.49, 95% CI=0.39-0.62, p<0.0001, number needed to treat=3.3). Despite continuation therapy, the risk of relapse within the first year following ECT is substantial, with the period of greatest risk being the first 6 months. The largest evidence base for efficacy in post-ECT relapse prevention exists for tricyclic antidepressants. Published evidence is limited or non-existent for commonly used newer antidepressants or popular augmentation strategies. Maintenance of well-being following successful ECT needs to be improved.

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.

Pharmacological strategies in the prevention of relapse after electroconvulsive therapy

OBJECTIVE

To determine whether starting antidepressant medication at the start of electroconvulsive therapy (ECT) reduces post-ECT relapse and to determine whether continuation pharmacotherapy with nortriptyline (NT) and lithium (Li) differs in efficacy or adverse effects from continuation pharmacotherapy with venlafaxine (VEN) and Li.

METHODS

During an acute ECT phase, 319 patients were randomized to treatment with moderate dosage bilateral ECT or high-dosage right unilateral ECT. They were also randomized to concurrent treatment with placebo, NT, or VEN. Of 181 patients to meet post-ECT remission criteria, 122 (67.4%) participated in a second continuation pharmacotherapy phase. Patients earlier randomized to NT or VEN continued on the antidepressant, whereas patients earlier randomized to placebo were now randomized to NT or VEN. Lithium was added for all patients who were followed until relapse or 6 months.

RESULTS

Starting an antidepressant medication at the beginning of the ECT course did not affect the rate or timing of relapse relative to starting pharmacotherapy after ECT completion. The combination of NT and Li did not differ from VEN and Li in any relapse or adverse effect measure. Older age was strongly associated with lower relapse risk, whereas the type of ECT administered in the acute phase and medication resistance were not predictive. Across sites, 50% of the patients relapsed, 33.6% continued in remission 6 months after ECT, and 16.4% dropped out.

CONCLUSIONS

Starting an antidepressant medication during ECT does not affect relapse, and there are concerns about administering Li during an acute ECT course. Nortriptyline and VEN were equally effective in prolonging remission, although relapse rates after ECT are substantial despite intensive pharmacology. As opposed to the usual abrupt cessation of ECT, the impact of an ECT taper should be evaluated.

The validity of the severity-psychosis hypothesis in depression

BACKGROUND

Psychotic depression (PD) is classified as a subtype of severe depression in the current diagnostic manuals. Accordingly, it is a common conception among psychiatrists that psychotic features in depression arise as a consequence of depressive severity. The aim of this study was to determine whether the severity of depressive and psychotic symptoms correlate in accordance with this "severity-psychosis" hypothesis and to detect potential differences in the clinical features of PD and non-psychotic depression (non-PD).

METHODS

Quantitative analysis of Health of the Nation Outcome Scales (HoNOS) scores from all patients admitted to a Danish general psychiatric hospital due to a severe depressive episode in the period between 2000 and 2010 was performed.

RESULTS

A total of 357 patients with severe depression, of which 125 (35%) were of the psychotic subtype, formed the study sample. Mean HoNOS scores at admission differed significantly between patients with non-PD and PD on the items hallucinations and delusions (non-PD=0.33 vs. PD=1.37, p<0.001), aggression (non-PD=0.20 vs. PD=0.36, p=0.044) and on the total score (non-PD=10.55 vs. PD=11.87, p=0.024). The HoNOS scores on the two items "depression" and "hallucinations and delusions" were very weakly correlated.

LIMITATIONS

Diagnoses were based on normal clinical practice and not formalized research criteria.

CONCLUSIONS

The symptomatology of PD and non-PD differs beyond the mere psychosis. Furthermore, severity ratings of depressive and psychotic symptoms are very weakly correlated. These findings offer further support to the hypothesis stating that the psychotic- and non-psychotic subtypes of depression may in fact be distinct clinical syndromes.

Adjunctive psychotropic medications during electroconvulsive therapy in the treatment of depression, mania, and schizophrenia

Current guidelines regarding concomitant antidepressants during electroconvulsive therapy (ECT) are inconsistent. Although the American Psychiatric Association Task Force on ECT discouraged combination antidepressant treatment, owing to the minimal evidence for enhanced efficacy and concern about increased adverse effects, combination treatment is recommended and considered routine for many practitioners in the United States and other parts of the world. Considering the increasing levels of treatment resistance among patients referred for ECT and the high relapse rate after acute ECT, the role of concomitant antidepressant pharmacotherapy during ECT should be reevaluated. More research, however, is needed to explore the impact of administering specific antidepressants during acute and maintenance ECT (M-ECT), on antidepressant efficacy and cognitive adverse effects. This will require appropriately controlled studies of ECT medication combinations that include attention to a range of cognitive function measures and clinical response. In addition, the role of combination ECT and psychotropic medication in the treatment of mania and schizophrenia continues to receive attention, particularly in those patients who have shown inadequate responses to psychotropic medication alone. Although there is insufficient evidence to support the routine addition of antipsychotic medications to ECT during the treatment of acute mania, the literature suggests that it is unnecessary to discontinue antipsychotic medication when ECT is added to the treatment of a manic patient that has been unresponsive to pharmacological treatment. Despite the lack of well-controlled studies, the existing literature suggests that combination ECT and antipsychotic treatment is a useful option for patients with schizophrenia who are unresponsive to pharmacological interventions alone, and its adverse effect profile does not seem different from that seen with ECT alone.

Combination of pharmacotherapy with electroconvulsive therapy in prevention of depressive relapse: a pilot controlled trial

OBJECTIVE

Relapse rates after electroconvulsive therapy (ECT) remain high with standard treatments. We aimed to test the efficacy of an early administered continuation pharmacotherapy (c-pharm early) strategy in prevention of post-ECT relapse.

METHOD

A 20-week, randomized, double-blind, placebo-controlled trial. Patients aged 18 to 65 years diagnosed with Diagnostic and Statistical Manual of Mental Disorders major depressive disorder, with or without psychotic features, with initial Montgomery-Asberg Depression Rating Scale scores higher than 22, underwent 8 bilateral ECT sessions (2 per week). Randomization to c-pharm early, c-pharm late, and placebo groups in 2:2:1, respectively, was performed at the completion of the fourth ECT session. After randomization, subjects in the c-pharm early group were given sertraline at 150 mg/d. Subjects in the c-pharm late group were first given placebo, which was substituted with sertraline at 150 mg/d at the completion of the eight ECT. Relapse was defined as a Montgomery-Asberg Depression Rating Scale score of 16 or higher.

RESULTS

Seventy-three percent of the patients responded to the given treatment. The relapse rates were 12.5% in the c-pharm early group, 28% in the c-pharm late group, and 67% in the placebo group (P = 0.09). The c-pharm early strategy resulted in significantly lower relapse rates and longer well time compared with the placebo (P = 0.04). When the trend with the initiation of the c-pharm intervention was investigated in the 3 groups with equally spaced trend weights, the time of initiation was found to have a significant effect on the probability of the remaining well (P = 0.03).

CONCLUSIONS

Comparative efficacy of c-pharm early and late strategies in providing improved protection against post-ECT relapse of major depressive disorder needs to be further explored.

Is the antidepressive effect of second-generation antidepressants a myth?

Two recent meta-analyses on second-generation antidepressants versus placebo in mild to moderate forms of major depression, based on data on all randomized clinical trials using the Hamilton Depression Scale (HAMD) submitted to FDA, have shown an effect size of approximately 0.30 in favour of antidepressants in the acute therapy of major depression. The clinical significance of an effect size at this level was found to be so poor that these meta-analyses have subscribed to the myth of an exclusively placebo-like effect of second-generation antidepressants. A re-allocation of HAMD items focusing on those items measuring severity of clinical depression, the HAMD6, has identified effect sizes of >or=0.40 for second-generation antidepressants in placebo-controlled trials for which even a dose-response relationship can be demonstrated. In the relapse-prevention phase during continuation therapy of patients with major depression, the advantage of second-generation antidepressants over placebo was as significant as in the acute therapy phase. To explore a myth is not to deny the facts but rather to re-allocate them.

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.

The safety of the electroconvulsive therapy-escitalopram combination

It has been suggested that the efficacy of electroconvulsive therapy (ECT) in the treatment of major depressive episodes may be enhanced by concurrent administration of antidepressant medication. Therefore, the issue of how safe the combination of these 2 treatment modalities is warrants investigation. Escitalopram (ESC) is a novel selective serotonin reuptake inhibitor that seems to have a favorable side effect profile. To the best of our knowledge, there is no report on the safety of the ECT-ESC combination. We report the cases of 3 female inpatients with major depressive episode--two in the context of major depressive disorder and one in the context of bipolar disorder I--who underwent ECT while concurrently receiving ESC (20 mg/d) as part of their regimen. In all cases, the combination was well tolerated, and only minimal side effects were reported.

Electroconvulsive therapy and its different indications

In spite of recent developments in the pharmacotherapy of depressive disorders, the delay until clinical improvement can be achieved, and the considerable rate of nonresponse and nonremission, are major problems which remain unresolved. Electroconvulsive therapy (ECT) is a nonpharmacologic biological treatment which has been proven to be a highly effective treatment option, predominantly for depression, but also for schizophrenia and other indications. Though there is a lack of controlled investigations on long-term treatments, ECT can also be used for relapse prevention during maintenance therapies. The safety and tolerability of electroconvulsive treatment have been enhanced by the use of modified stimulation techniques and by progress in modern anesthesia. Thus, today a safe treatment can also be offered to patients with higher somatic risks. ECT still represents an important option, especially in the therapy of treatment-resistant psychiatric disorders after medication treatment failures. Earlier consideration of ECT may reduce the rate of chronic and difficult-to-treat psychiatric disorders.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines

A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.

Long-term follow-up after successful electroconvulsive therapy for depression: a 4- to 8-year naturalistic follow-up study

OBJECTIVES

A long-term follow-up of depressed patients responsive to electroconvulsive therapy (ECT) with intensive pre-ECT pharmacotherapy treatment failure who also participated in a 6-month trial directly post-ECT in which imipramine was compared with placebo for relapse prevention.

METHODS

A total of 26 patients responsive to ECT who participated in the 6-month continuation trial were invited 4 to 8 years later to assess their follow-up status. The groups with and without relapse within 6 months were compared with regard to recurrence of depression up to 8 years later. Recurrence was defined as a new episode of depression that needed antidepressant medication and/or readmission in hospital and/or a new ECT course.

RESULTS

At the time of follow-up (mean duration, 6.8 years), the recurrence rate of depression for the total sample was 42.3%. There was no significant difference in the recurrence rates and number of recurrences between the nonrelapse and relapse groups. The small study population limits generalization of the results; the design of the study is naturalistic and retrospective.

CONCLUSION

In our small sample of depressed patients with pharmacotherapy treatment failure, recurrence is not influenced by relapse after terminating ECT. Continuation of medication started immediately after ECT seems to be an important factor in preventing recurrence.

The influence of concomitant neuroleptic medication on safety, tolerability and clinical effectiveness of electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is still considered to be the most efficacious treatment option in major depressive disorder and treatment-resistant schizophrenia. Unfortunately, in some cases patients do not respond sufficiently to conventional unilateral ECT, or even to bilateral or high dose ECT. In these cases, concomitant pharmacotherapy can be a useful augmentation strategy to improve clinical effectiveness. Interestingly, there is not much data about ECT and concomitant neuroleptic medication.

METHOD

We evaluated 5482 treatments in 455 patients in our retrospective study to see whether there might be differences between combination therapies (ECT and concomitant neuroleptic medication) and ECT monotherapy. We focused on clinical effectiveness and tolerability; furthermore we investigated treatment modalities and ictal neurophysiological parameters that might influence the treatment.

RESULTS

A total of 18.2% of all treatments were done with no psychotropic medication, 2.8% with a neuroleptic monotherapy. Seizure duration according to EEG derivations turned out to be significantly longer in patients treated with neuroleptics of lower antipsychotic potency, whereas seizure duration in EMG was shorter in treatments done with atypical substances. Postictal suppression was highest in treatments done with atypical neuroleptics, whereas the same group was lowest regarding convulsion energy and convulsion concordance indices. The best therapeutic effectiveness was seen in treatments done with atypical substances. Adverse effects were not influenced significantly by concomitant neuroleptic medication.

CONCLUSION

Our study suggests that there might be a clinical benefit by combining ECT treatment with neuroleptic medication; especially atypical substances seem to enhance improvement. The tolerability of ECT treatment was not influenced by concomitant neuroleptic medication.

The influence of concomitant antidepressant medication on safety, tolerability and clinical effectiveness of electroconvulsive therapy

BACKGROUND

A major problem in the treatment of severe depression is the onset latency until clinical improvement. So far, electroconvulsive therapy (ECT) is the most effective somatic treatment of depression. This holds especially true for treatment-refractory disturbances. However, not all patients respond to conventional unilateral ECT. In certain cases, subsequent clinical response can be achieved using bilateral or high-dose unilateral ECT. Also, a concomitant pharmacotherapy can be utilized to augment therapeutic effectiveness. Surprisingly, data in this field are widely lacking and only few studies showed advantages of an ECT/tricyclic antidepressant combination.

METHOD

We retrospectively evaluated 5482 treatments in 455 patients to investigate possible therapeutic advantages in combination therapies versus ECT monotherapy. Main outcome criteria were clinical effectiveness and tolerability. Moreover, treatment modalities and ictal neurophysiological parameters that might influence treatment outcome were analysed.

RESULTS

A total of 18.2% of our treatments were ECT monotherapy, 8.87% were done with one antidepressant. Seizure duration was unaffected by the most antidepressants. SSRI caused a lengthened seizure activity. Postictal suppression was lower in mirtazapine and higher in SSRI and SNRI treated patients. A significant enhancement of therapeutic effectiveness could be seen in the patient group receiving tricyclics, SSRI or mirtazapine. Serious adverse events were not recorded.

CONCLUSION

Our study supports the hypothesis that mirtazapine can be used to enhance the therapeutic effectiveness of ECT. Controlled studies are necessary to further investigate the possible advantages of ECT and pharmacotherapy combinations, especially the use of modern dually acting antidepressants which have proven their good effectiveness in treatment-resistant depression.

Combined use of ECT with duloxetine and olanzapine: a case report

A 38-year-old woman with medication-resistant major depression and posttraumatic stress disorder was treated with electroconvulsive therapy (ECT) concurrent with a duloxetine-olanzapine combination. The treatment resulted in complete resolution of major depression without any complications. This case report suggests that treatment with the combination of duloxetine and olanzapine concurrently with ECT was found safe and uncomplicated. The literature on the combined use of antidepressants and ECT is briefly reviewed.

Antidepressants for depressed elderly

BACKGROUND

Depression is a relatively common experience in older adults. The syndrome is associated with considerable distress, morbidity and service commitment. Approximately two thirds of patients presenting with severe forms will respond to antidepressant treatment and the last twenty years has witnessed a great increase in the number of these drugs. Older, frail people are particularly vulnerable to side effects.

OBJECTIVES

The aims of this review were to examine the efficacy of antidepressant classes, to compare the withdrawal rates associated with each class and describe the side effect profile of antidepressant drugs for treating depression in patients described as elderly, geriatric, senile or older adults, aged 55 or over.

SEARCH STRATEGY

The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR-Studies) was searched (2003-08-13). Reference lists of relevant papers and previous systematic reviews were hand searched for published reports and citations of unpublished studies.

SELECTION CRITERIA

Only randomised controlled trials were included. Trials had to compare at least two active antidepressant drugs in the treatment of depression.

DATA COLLECTION AND ANALYSIS

Reviewers extracted data independently. In examining efficacy, the reviewers assumed that people who died or dropped out had no improvement. Withdrawal rates irrespective of cause and specifically due to side effects were compared between drug classes. Relative risk (RR) for dichotomous data and weighted mean difference for continuous data were calculated with 95% confidence intervals (CI). Qualitative side effect data were reported in terms of ratios of side effects and percentage of patients experiencing specific side effects.

MAIN RESULTS

A total of 29 trials provided data for inclusion in the review. We were unable to find any differences in efficacy when comparing classes of antidepressants. However, as the trials contained relatively small numbers of patients, these findings may be explained by a type two error. Tricyclic antidepressants (TCAs) compared less favourably with selective serotonin reuptake inhibitors (SSRIs) in terms of numbers of patients withdrawn irrespective of reason (RR: 1.24, CI 1.04, 1.47) and number withdrawn due to side effects (RR: 1.30, CI 1.02, 1.64). Subgroup analyses demonstrated that TCA related antidepressants had similar withdrawal rates to SSRIs irrespective of reason of withdrawal (RR: 1.49, CI 0.74, 2.98) or withdrawal due to side effects (RR: 1.07, CI 0.43, 2.70). The qualitative analysis of side effects showed a small increased profile of gastro-intestinal and neuropsychiatric side effects associated with classical TCAs.

AUTHORS' CONCLUSIONS

Our findings suggest that SSRIs and TCAs are of the same efficacy. However, we have found some evidence suggesting that TCA related antidepressants and classical TCAs may have different side effect profiles and are associated with differing withdrawal rates when compared with SSRIs. The review suggests that classical TCAs are associated with a higher withdrawal rate due to side effect experience, although these results must be interpreted with caution due to the relatively small size of the review and the heterogeneity of the drugs and patient populations.

Électroconvulsivothérapie, utilité dans la dépression sévère du sujet de plus de 65 ans

The management of depression in subjects aged over 65 is based on the isolated or combined use of antidepressant chemotherapy, psychotherapy and electroconvulsive therapy. Electroconvulsive therapy, under general anaesthesia and use of curare, consists in producing a generalised seizure using a short, pulsed, electrical current administered via the transcranial route. There is renewed interest in electroconvulsive therapy with the development of specific rules and conditions for its use, together with the recruitment of depressed patients resistant to classical treatments in hospital settings. The efficacy of electroconvulsive therapy has been demonstrated in the elderly. The immediate side effects, related to the electrical stimulation and the seizure, such as headaches, nausea, confusion, and transient amnesia, regress within a few minutes or hours after the session. The limits of electroconvulsive therapy are the high risk of relapse on suspension of the sessions, relapse basically related to the severity of the depression. Consolidation electroconvulsive therapy provides new hope for better control of such relapses.

The combined treatment of venlafaxine and ECT in treatment-resistant depressive patients

Objective To evaluate the efficacy and safety of the combination treatment of ECT and venlafaxine among treatment-resistant depressive patients. Methods We reviewed 21 depressive patients who were treated with a combination of electroconvulsive therapy (ECT) and venlafaxine. The indication of the ECT-venlafaxine treatment was inadequate response to at least one antidepressant trial of adequate doses and duration. Propofol was used as an anesthetic agent during ECT treatments. Results Ninety percent of the patients benefited from the combined treatment. The responsivity to the combination treatment was not associated with high dose of venlafaxine. In most of the patients, the combined treatment was safe and well tolerated. Adverse reactions occurred in 57% of the patients and included concentration difficulties (four patients), memory problems (seven patients) and headache (one patient). No asystole was observed. Treatment was safe with a low dose of venlafaxine equal to or lower than 225 mg/day. Conclusions It seems that treatment of ECT combined with low dose venlafaxine and propofol as anesthetic agent is effective and safe. This strategy may be a therapeutic option in treatment-resistant depressive patients.

Effective use of electroconvulsive therapy in late-life depression

OBJECTIVE

To review literature pertaining to the efficacy, safety, and tolerability of electroconvulsive therapy (ECT) in treating late-life depression.

METHOD

We undertook a literature review with an emphasis on research studies published in the last 10 years.

RESULTS

There is a positive association between advancing age and ECT efficacy. Age per se does not necessarily increase the risk of cognitive side effects from ECT, but this risk is increased by age-associated neurological conditions such as Alzheimer's dementia and cerebrovascular disease. With appropriate evaluation and monitoring, ECT can be used safely in patients of very advanced age and in those with serious medical conditions. Several technical factors, including dose of electricity relative to a patient's seizure threshold, position of electrodes, frequency of administration, and total number of treatments, have an impact on the efficacy and cognitive side effects of ECT and need to be taken into account when administering ECT. Naturalistic studies have found that 50% of more of patients have a relapse of depression within 6 to 12 months of discontinuing acute ECT.

CONCLUSIONS

In recent years, there has been substantial progress in our understanding of the effect of technical factors on the efficacy and cognitive side effects of ECT. When administered in an optimal manner, ECT is a safe, well-tolerated, and effective treatment in older patients. Relapse of depression after response to ECT remains a significant problem, and there is a need for further research into the prediction and prevention of post-ECT relapse.

The Bech-Rafaelsen Melancholia Scale (MES) in clinical trials of therapies in depressive disorders: a 20-year review of its use as outcome measure

OBJECTIVE

To evaluate the psychometric properties of the Bech-Rafaelsen Melancholia Scale (MES) by reviewing clinical trials in which it has been used as outcome measure.

METHOD

The psychometric analysis included internal validity (total scores being a sufficient statistic), interobserver reliability, and external validity (responsiveness in short-term trials and relapse prevention in long-term trials).

RESULTS

The results showed that the MES is a unidimensional scale, indicating that the total score is a sufficient statistic. The interobserver reliability of the MES has been found adequate both in unipolar and bipolar depression. External validity including both relapse, response and recurrence indicated that the MES has a high responsiveness and sensitivity.

CONCLUSION

The MES has been found a valid and reliable scale for the measurement of changes in depressive states during short-term as well as long-term treatment.

Augmentation of seizure induction in electroconvulsive therapy: a clinical reappraisal

OBJECTIVE

Missed or abortive seizures during electroconvulsive therapy (ECT) may preclude completion of an effective course of treatment in some cases. Seizure augmentation, using proconvulsant agents, has been used to overcome resistance to the induction and continuation of seizure activity. In this review, we analyze published clinical data on the effects and safety of seizure augmentation techniques.

METHOD

Clinical studies and case reports were obtained through a MEDLINE literature search from 1966 to 2001, cross-referencing ECT and proconvulsant agents. Article references were also scanned for relevant studies.

RESULTS AND CONCLUSIONS

Data from clinical trials indicate that augmentation facilitates seizure induction when maximal electrical stimuli fail. Anesthetic modifications, including hyperventilation and substitution with etomidate, ketamine, or other agents, often are successful in overcoming seizure resistance and compare favorably with the use of caffeine. In a few studies, augmentation enabled the use of lower stimulus intensities and fewer treatments without loss of efficacy, even in patients not resistant to seizure induction. However, effects of proconvulsants must be reconciled with increasing evidence of the importance of stimulus dosing relative to seizure threshold and other parameters, now considered key to the efficacy of ECT. Further investigations of pharmacologic augmentation could facilitate the administration of ECT and could provide further insights concerning parameters of seizure efficacy and the mechanism of action underlying convulsive therapies.

Residual symptoms in depression an emerging therapeutic concept

Cushing's syndrome is due to chronic glucocorticoid excess that may have various etiologies. The most common endogenous form is pituitary-dependent bilateral adrenal hyperplasia, which is termed Cushing's disease. Major depression occurs in more than half of the cases. The presence of depressive symptoms connotes severity of clinical presentation and, in patients with hypothalamic-pituitary forms, entails prognostic value. Medical treatment may be used while awaiting more definitive solutions for the illness by surgery. The inhibitors of steroid production (e.g., ketoconazole, metyrapone and aminoglutethimide), rather than antidepressant drugs, are generally successful in lifting depression as well as other disabling symptoms. Since central serotonergic regulation could have a role in the course of Cushing's disease, serotonin antagonists (e.g., cyproheptadine, ritanserin and ketanserin) have been employed. Findings related to the pharmacological response of depression in Cushing's disease were found to have implications for the pathophysiology of depression and the potential involvement of the hypothalamic-pituitary-adrenal axis (HPA axis) in resistance and tolerance to antidepressant drugs. The use of serotonergic drugs in Cushing's disease may yield important insights in the understanding of serotonergic regulation both in Cushing's disease and in the HPA axis in nonendocrine major depression.

The Bech-Rafaelsen Mania Scale in clinical trials of therapies for bipolar disorder: a 20-year review of its use as an outcome measure

Over the last two decades the Bech-Rafaelsen Mania Scale (MAS) has been used extensively in trials that have assessed the efficacy of treatments for bipolar disorder. The extent of its use makes it possible to evaluate the psychometric properties of the scale according to the principles of internal validity, reliability, and external validity. Studies of the internal validity of the MAS have demonstrated that the simple sum of the 11 items of the scale is a sufficient statistic for the assessment of the severity of manic states. Both factor analysis and latent structure analysis (the Rasch analysis) have been used to demonstrate this. The total score of the MAS has been standardised such that scores below 15 indicate hypomania, scores around 20 indicate moderate mania, and scores around 28 indicate severe mania. The inter-observer reliability has been found to be high in a number of studies conducted in various countries. The MAS has shown an acceptable external validity, in terms of both sensitivity and responsiveness. Thus, the MAS was found to be superior to the Clinical Global Impression scale with regard to responsiveness, and sensitivity has been found to be adequate, with the MAS able to demonstrate large drug-placebo differences. Based on pretreatment scores, trials of antimanic therapies can be classified into: (i) ultrashort (1 week) therapy of severe mania; (ii) short-term therapy (3 to 8 weeks) of moderate mania; (iii) short-term therapy of hypomanic or mixed bipolar states; and (iv) long-term (12 months) therapy of bipolar states. The responsiveness of MAS is such that the scale has been able to demonstrated that typical antipsychotics are effective as an ultrashort therapy of severe mania; that lithium and anticonvulsants are effective in the short-term therapy of moderate mania; and that atypical antipsychotics, electroconvulsive therapy (ECT) and transcranial magnetic stimulation seem to have promising effects in the short-term therapy of moderate mania. In contrast, the scale has been used to demonstrate that calcium antagonists (e.g. verapamil) are ineffective in the treatment of mania. MAS has also been used to add to the literature on the evidence-based effect of lithium as a short-term therapy for hypomania or mixed bipolar states and as a long-term therapy of bipolar states.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Acute and continuation treatment of major depressive disorder

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was 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. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

Relapse of depression after ECT: a review

Relapse of severe depression after successful treatment with electroconvulsive therapy (ECT) continues to be a major problem. We review the literature on relapse after ECT and factors that predict relapse. Early studies showed that the relapse rate was approximately 50% without follow-up treatment and that the majority of these relapses occurred in the first 6 months. More recent studies have found even higher rates in delusional depression and possibly in "double depression." Studies of biological markers as predictors of relapse were examined. Six of nine studies of the dexamethasone suppression test and one study of cortisol hypersecretion show that post-ECT nonsuppressors are at higher risk; although insensitive for diagnostic purposes, this test may be useful, when persistently abnormal, as a predictor of relapse. Studies of the thyrotropin-releasing hormone stimulation test and shortened rapid eye movement sleep latency are inconclusive. Medication resistance pre-ECT has been shown to predict relapse in two studies and highlights the need for more aggressive and effective treatment in this group. Further research into the prediction and prevention of depressive relapse after ECT is needed, and the field anxiously awaits current trials comparing ECT with combination lithium and nortriptyline.

Seizure activity and safety in combined treatment with venlafaxine and ECT: a pilot study

Some authors have described the combined use of ECT and psychotropic drugs, emphasizing possible interactions and synergisms of this combined therapy. We are unaware of reports of the concurrent use of the new antidepressant venlafaxine with ECT. The goals of our study were to assess the possible effects of venlafaxine on seizure length during ECT and the possible cardiovascular effects of this combined treatment. Nine severely ill, depressed patients were treated simultaneously with bilateral ECT and venlafaxine 150 mg/day and were compared with nine control, depressed subjects taking tricyclic antidepressants (TCA) and ECT. No patients had prolonged seizures and no spontaneous/tardive seizures outside ECT were observed. With regard to mean seizure length, no statistically significant differences were observed between the control group and the venlafaxine group. Neither significant increases in arterial blood pressure nor electrocardiographic recording abnormalities were found in venlafaxine patients when compared with the tricyclic group. Even though the small number of patients used is a significant limitation of this study, we found that combined venlafaxine and ECT appears to be safe when used in depression.

Serotonin, cerebral blood flow, and cerebral metabolic rate in geriatric major depression and normal aging

While there is substantial evidence for abnormalities in serotonin (5-HT) neurotransmission in major depressive disorder (MDD), almost all of the findings derive from studies of young adults. Moreover, relatively little research has assessed brain 5-HT transmission in vivo. Neuroendocrine studies do not permit evaluation of a range of brain regions, but only the limited circuitry associated with hormone release. Data from autopsy studies are limited by the difficulties of assessment of the acute clinical picture before death, and by post-mortem artifacts. In vivo neuroimaging techniques overcome many of the methodological limitations of both these approaches. There is a large body of imaging data indicating regional cerebral blood flow (rCBF) and cerebral metabolic rate (rCMR) decrements both with aging and in patients with MDD. While the physiological bases for these phenomena are largely unknown, changes in brain 5-HT function may be involved. Neuroanatomical studies have revealed an intricate network of 5-HT-containing neurons within the cerebral microvasculature, with physiological evidence for serotonergic control of both rCBF and rCMR. Acute pharmacological challenges are available to probe brain 5-HT function. Such paradigms, using neuroendocrine responses as endpoints, have been of some utility in predicting outcome with antidepressant treatment. The role of 5-HT dysregulation in geriatric MDD takes on more importance given concerns regarding putative reduced efficacy of serotonin-specific reuptake inhibitors (SSRIs) in this population. If this is due to diminished responsivity of 5-HT systems, then the ability to identify antidepressant nonresponders via 5-HT challenge in combination with neuroimaging measures may have important clinical utility.