ELECTROCONVULSIVE THERAPY AND DEPRESSION. 3. A METHOD FOR PROGNOSIS

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.

Appropriateness for electroconvulsive therapy (ECT) can be assessed on a three-item scale

Electroconvulsive therapy (ECT) is the most effective and rapid treatment for severe depression; however, it should be prescribed to the limited number of patients with severe mood and psychotic disorders for whom it is clearly appropriate. We present an assessment scale that we hypothesize can be used to predict a patient's appropriateness for ECT, based on the severity, heritability, and episodic nature of their depression. This scale is offered as a tool to help the practitioner and patient gain a sense of how well the patient fits the profile of someone for whom ECT is a reasonable treatment option.

Melancholia

PURPOSE OF REVIEW

The key question for melancholia is whether it should have status as a separate disorder and the literature of the last 12-24 months is surveyed largely from that perspective.

RECENT FINDINGS

A number of interesting findings have appeared across a broad range of issues, but, with the possible exception of some large clinical trials, remain largely unreplicated.

SUMMARY

Supporters of melancholia as a distinct entity will find little comfort in the recent literature.

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.

Major depression: an illness with objective physical signs

Major depression is an illness with objective physical signs occurring with some consistency. These signs are retardation of movements and diminished gestures and expressions. The patient may appear tired, self-concerned, bored, and inattentive and display a loss of interest in the surroundings. Anxiety is a conspicuous and an integral element of affective state and may be expressed by severe restlessness and agitation. Muscle tension, wringing of hands, weeping and moaning, repeating over and over in a monotonous and stereotyped way phrases expressive of misery are all important clinical signs of major depression. Similarly tachycardia, dry tongue/mouth, sweaty palms and/or bodily extremities, cold clammy skin, pallor, pupillary dilatation, tremor, and the fluctuations in blood pressure with wide pulse pressure are all important and give away the underlying distress. These signs have formed an integral part of both the Hamilton Depression Rating Scale and the Montgomery-Asberg Depression Rating Scale as they have a positive correlation with the diagnosis and the severity of illness. Current practice of operational criteria does not help exclude patients with subjective perception of distress and also fails to make room for aetiopathogenesis. The DSM-IV does not include these physical signs as an integral part of the clinical picture of depression, consequently leaving the diagnosis of MDE to subjective criteria and perceptions. This could also explain a large placebo response in recent randomised controlled clinical trials.

Which depressed patients respond to ECT? The Nottingham results

The Nottingham electroconvulsive therapy (ECT) trial was designed with a simulated treatment group to test prospectively the power of delusions or agitation to predict response. The response of patients without retardation and without delusions was examined retrospectively as well because of doubts over the usefulness of ECT for this subgroup. Deluded/nondeluded and agitated/nonagitated subtypes responded significantly to real treatment. Neither delusions nor agitation predicted greater treatment response. Patients without retardation, with or without delusions responded to real ECT, supporting the continuing prescription of ECT for these patients as well.

The subcategorization of nonpsychotic depression in behavioral and nonbehavioral research

In terms of the traditional dichotomy it has been relatively easy to make assured diagnoses of endogenous depression, but not of neurotic depression. In consequence, some have suggested that the diagnosis of neurotic depression be dropped and that the cases previously so categorized be recognized as heterogeneous nonpsychotic depressions. Nevertheless, numerous behavioral outcome studies have treated groups of nonpsychotic depressions as homogeneous. The present investigation compared the incidence of this usage in behavioral and nonbehavioral studies. It was found that behavioral workers are 2.5 times as likely as nonbehavioral workers to ignore the heterogeneity. Attention is drawn to the practicality of positive diagnosis of neurotic depression.

Psychomotor retardation and agitation in depression. Relationship to age, sex, and response to treatment

Patients with primary affective disorder who had either psychomotor agitation alone or psychomotor retardation alone were studied. Compared to psychomotor retardation, psychomotor agitation appears to be seen more frequently in women, older patients, and individuals who have a late onset to their illness. In addition, those with agitation alone appeared to have a better and faster response to electroconvulsive therapy.

Childhood experience and depression

The possibility of a relationship between early parental loss and mental illness, suicide, or delinquency in later life is a well-known, although by no means universally accepted, theory. In this investigation, we have attempted to compare patients with carefully matched controls and to investigate, when possible, the various categories of depression separately. Also, as we felt that a study concerned with childhood deprivation based solely on the physical absence of parents would tell us little of the daily emotional experiences of the child, we have attempted to take into account the quality of the family relationships present in childhood.

ELECTROCONVULSIVE THERAPY AND DEPRESSION. I. THE PROGNOSTIC SIGNIFICANCE OF CLINICAL FACTORS

Since its introduction by Cerletti and Bini in 1938 electroconvulsive therapy has become a major bulwark of therapy in psychiatric practice. Until a few years ago, before the introduction of the psychotropic drugs, it was the commonest method of physical treatment employed in psychiatry.