Is there a delay in the onset of the antidepressant effect of electroconvulsive therapy?

Novel rapid treatment options for adolescent depression

There is an urgent need for novel fast-acting antidepressants for adolescent treatment-resistant depression and/or suicidal risk, since the selective serotonin reuptake inhibitors that are clinically approved for that age (i.e., fluoxetine or escitalopram) take weeks to work. In this context, one of the main research lines of our group is to characterize at the preclinical level novel approaches for rapid-acting antidepressants for adolescence. The present review summarizes the potential use in adolescence of non-pharmacological options, such as neuromodulators (electroconvulsive therapy and other innovative types of brain stimulation), as well as pharmacological options, including consciousness-altering drugs (mainly ketamine but also classical psychedelics) and cannabinoids (i.e., cannabidiol), with promising fast-acting responses. Following a brief analytical explanation of adolescent depression, we present a general introduction for each therapeutical approach together with the clinical evidence supporting its potential beneficial use in adolescence (mainly extrapolated from prior successful examples for adults), to then report recent and/or ongoing preclinical studies that will aid in improving the inclusion of these therapies in the clinic, by considering potential sex-, age-, and dose-related differences, and/or other factors that might affect efficacy or long-term safety. Finally, we conclude the review by providing future avenues to maximize treatment response, including the need for more clinical studies and the importance of designing and/or testing novel treatment options that are safe and fast-acting for adolescent depression.

No time to lose: the current state of research in rapid-acting psychotherapeutics

The vast majority of treatments for psychiatric and substance use disorders take weeks to work. Notable exceptions to this rule exist, with some treatments such as intravenous ketamine resolving symptoms in minutes to hours. Current research is focused on identifying novel approaches to rapid-acting psychotherapeutics. Promising results from studies of novel classes of drugs and innovative brain stimulation therapies are currently being studied through both clinical and pre-clinical research, as described here. Research focused on understanding neurobiological mechanisms, effective therapeutic context, and implementation approaches are needed to maximize the potential reach of these therapies.

Electroconvulsive therapy: a review on indications, methods, risks and medication

This paper reviews and presents data of practical impact for those administering electroconvulsive therapy (ECT). In the first section, physical and physiological aspects of the stimulus as well as methods of stimulation are discussed. The second section deals with indications for ECT, efficacy and treatment modalities such as seizure duration, treatment frequency and total number of ECT applications. The last section is devoted to side effects, risks, comedication and comorbidity.

Improvement after two sessions of electroconvulsive therapy predicts final remission in in-patients with major depression

OBJECTIVE

To investigate whether early improvement, measured after two electroconvulsive therapy (ECT) sessions, is a good predictor of eventual remission in severely depressed in-patients receiving ECT.

METHOD

A prospective cohort study was performed that included 89 major depressive disorder in-patients treated with bilateral ECT. Sensitivity, specificity, and predictive values were computed for various definitions of early improvement (15%, 20%, 25%, and 30% reduction on the Montgomery Asberg depression rating scale (MADRS) score) after 1 week (i.e. two sessions) of ECT regarding prediction of remission (final MADRS score ≤ 9).

RESULTS

A 15% reduction in MADRS score appeared to be the best definition of early improvement, with modest sensitivity (51%) and relatively good specificity (79%). Kaplan-Meier analysis showed a more than 2-week shorter time to remission in patients with early improvement compared with patients lacking early improvement.

CONCLUSION

Early improvement during an ECT course may be assessed after two ECT sessions. Such improvement, defined as a 15% reduction in the MADRS score, is a moderately sensitive predictor for eventual remission in an in-patient population with severe major depression.

Early improvement as a predictor of final remission in major depressive disorder: New insights in electroconvulsive therapy

BACKGROUND

Early improvement to antidepressant drugs predicts remission, but the predictive value of early improvement to electroconvulsive therapy (ECT) is still unclear. The main aim of this study was to determine the optimal definition of early improvement in the treatment of major depressive disorder (MDD) with ECT, by analyzing its value as a predictor of remission.

METHODS

A naturalistic study was conducted in 87 adult MDD patients treated with acute ECT. ROC curves were generated to identify the best time point (week 1 or 2 of treatment) predicted remission. Sensibility, specificity, and predictive values were calculated for several definitions of early improvement previously proposed in the literature (20%, 25%, 30%, and 35%). Complementary, time to remission was analyzed and a logistic regression model was performed to further characterize the impact of the optimal definition of early improvement on remission while adjusting for other clinically relevant variables.

RESULTS

A 30% reduction in the HAM-D score after 2 weeks was identified as the optimal definition of early improvement, with acceptable sensitivity (76%), and specificity (67%). Complementary analyses provided further support for this definition showing a shorter time to remission and a significant effect adjusted for the rest of variables.

LIMITATIONS

Relatively small sample size, ECT restricted to brief bilateral treatment.

CONCLUSIONS

Early improvement, defined as a 30% of reduction in the HAM-D₂₁ score at week 2, is a good predictor of remission in MDD patients treated with bilateral ECT, with potential clinical impact. Lack of early improvement could indicate a need for further changes in treatment strategies.

On lightening up: improvement trajectories in recovery from depression

This article is an extended consideration of a recent editorial (Parker, 1996), and seeks to argue the importance of studying both onset and trajectories of improvement in those with depressive disorders.

Onset of clinical improvement of depressive illness following electroconvulsive therapy

Aims and method

To examine the onset and course of clinically observable improvement in patients receiving electroconvulsive therapy (ECT). A prospective design was used In which 19 consecutive patients receiving ECT were followed up from commencement to termination of ECT. The Clinical Global Improvement Scale was administered at every ECT session to monitor their Improvement.

Results

Eleven of the 19 subjects Improved minimally and another subject Improved substantially after the first two ECT treatments.

Clinical implications

ECT produces clinically observable improvement in depression within a few days of starting treatment perhaps earlier than is generally acknowledged.

Is the Ultimate Treatment Response Predictable with Early Response in Major Depressive Episode?

INTRODUCTION

New evidence suggests that the efficacy of antidepressants occurs within the first weeks of treatment and this early response predicts the later response. The purpose of the present study was to investigate if the partial response in the first week predicts the response at the end of treatment in patients with major depressive disorder who are treated with either antidepressant medication or electroconvulsive therapy.

METHODS

Inpatients from Dokuz Eylül University Hospital with a major depressive episode, treated with antidepressant medication (n=52) or electroconvulsive therapy (ECT) (n=48), were recruited for the study. The data were retrospectively collected to decide whether a 25% decrease in the Hamilton Depression Rating Scale (HDRS) score at the first week of treatment predicts a 50% decrease at the third week using validity analysis. In addition, the effects of socio-demographic and clinical variables on the treatment response were assessed.

RESULTS

A 25% decrease in the HDRS score in the first week of treatment predicted a 50% decrease in the HDRS score in the third week with a 78.3% positive predictive value, 62.1% negative predictive value, 62.1% sensitivity, and 78.3% specificity for antidepressant medications and an 88% positive predictive value, 52.2% negative predictive value, 66.7% sensitivity, and 80% specificity for ECT. The number of previous hospitalizations, comorbid medical illnesses, number of depressive episodes, duration of illness, and duration of the current episode were related to the treatment response.

CONCLUSION

Treatment response in the first week predicted the response in the third week with a high specificity and a high positive predictive value. Close monitoring of the response from the first week of treatment may thus help the clinician to predict the subsequent response.

Stimulus characteristics in electroconvulsive therapy. A pragmatic review

The process of normalization electroconvulsive therapy (ECT) requires, among other actions, disseminating the latest information on this technique. One of the most complex aspects is the electrical stimulus, whose knowledge should be spread and put into practice. In this paper we review the available information about frequency and number of ECT sessions, and efficacy of each electrode placement. We also present two approaches to determine the ECT charge: stimulus titration versus age-based method; and the limitations of the summary metrics of charge, being necessary to expand our knowledge of the parameters that configure the stimulus: duration, current amplitude frequency and pulse width.

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.

Affective disorder and epilepsy comorbidity: implications for development of treatments, preventions and diagnostic approaches

Concepts pertaining to affective disorder and epilepsy comorbidity are contributing appreciably to improvements in patient care. Several antiepileptic treatments have become important components of the management of bipolar affective disorder. In contrast, little progress has emerged in developing clinical applications of the anticonvulsant properties of the antidepressants in the treatment of the epilepsies. The slow onset of action of the antidepressants remains a major impediment to fully effective treatment of depressive episodes. Nevertheless, studies from experimental epileptology demonstrate that the anticonvulsant effects of the antidepressants occur rapidly and as a consequence of noradrenergic and/or serotonergic activation. These studies also demonstrate that adequate initial doses of the antidepressants are essential to rapid onset of anticonvulsant action. Pharmacokinetically valid loading dose paradigms are seemingly avoided with antidepressant drugs in humans because of potential toxicities and/or patient unacceptability. However, substantial progress has been made in reducing the adverse effect liability of the antidepressants. No longer is convulsive liability considered to stem from the therapeutic mechanisms of the anti-depressants. Rather, noradrenergic and serotonergic influences have demonstrable anticonvulsant properties. Other side effects may also be separable from the anticonvulsant and antidepressive effects of antidepressive treatments. The concept that the protracted process of antidepressant-induced beta-noradrenergic down-regulation is an essential prelude to the onset of mood benefit is no longer a sustainable premise. Nevertheless, increasing evidence underlies the possibility that knowledge of serotonergic and noradrenergic regulatory processes can be used to design strategies that will hasten the onset of antidepressive action. Similar optimism pervades efforts to determine the possibility that dual inhibition of serotonin and norepinephrine transporters will hasten onset of antidepressive action. Moreover, because noradrenergic and serotonergic systems are determinants of predisposition to seizures and to dysfunctional affective episodes, augmentation strategies may also be applicable to the use of antidepressant drugs in epilepsy and to the use of antiepileptic drugs such as carbamazepine in mood disorders. Recent studies have demonstrated that, in part, the therapeutic effectiveness of carbamazepine may stem from its marked capacity to elevate serotonin concentrations in the extracellular fluid of the brain via mechanisms that differ from those of the membrane reuptake inhibitors. Evidence suggests that the epilepsies and affective disorders may arise from a multiplicity of neurobiological abnormalities. A disorder in one individual may arise via different mechanisms than a phenomenologically similar disorder in another individual. Thus, diagnostic tools are needed to make mechanistic distinctions among individuals so that treatments can be appropriately developed and selected. In terms of epileptogenesis and affective disorder progression, neuroprotective paradigms for one individual may differ from those needed for another. Moreover, diagnostic technologies that are adequate to detect genetically and/or experientially determined vulnerability before the onset of a seizure or dysfunctional affective episode may be valuable steps toward achieving goals of prevention.

Effects of single and repeated electroconvulsive shock on the social and agonistic behaviour of resident rats

The aim of this study was to determine whether electroconvulsive shock (ECS, an established antidepressant treatment), like acute and chronic antidepressant drug treatments, produces similar differential effects on the behavioural profile of resident rats expressed during social encounters with unfamiliar intruder conspecifics (resident-intruder paradigm). Thirty minute pretreatment with a single ECS suppressed both investigation and aggression directed at intruders concomitant with increased flight behaviour and marked sedation. Behavioural disruption subsided over the following 24 h. In contrast, resident rats subjected to bi-daily ECS treatment expressed elevated aggression at days 7 (four shocks) and 14 (eight shocks). Eight days after the last ECS treatment the behaviour of the resident rats had returned to pretreatment values. Additional studies showed that bi-daily ECS treatment nearly abolished 5-HT(2C) receptor-mediated hypolocomotion induced by acute m-chlorophenylpiperazine (mCPP, 2.5 mg/kg sc) challenge 24 h following 2 ECSs, while 4 ECSs only enhanced 5-HT(2A) receptor-mediated head shakes induced by 1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (DOI, 2.0 mg/kg sc). These studies demonstrate that repeated ECS treatment increases the aggressive behaviour of resident rats which may be associated with adaptive changes in 5-HT(2C) and 5-HT(2A) receptor-mediated function. It remains to be seen whether adaptive changes in 5-HT(2C) receptor function represent a common mechanism of clinical antidepressant efficacy.

Characteristics of responders and nonresponders to brief-pulse right unilateral ECT in a controlled clinical trial

In a double-blind, randomized controlled study of electroconvulsive therapy (ECT) in patients with major depression, 7 of the 17 patients allocated to the right unilateral group failed to respond to treatment. The nonresponders were subsequently openly treated with bitemporal treatment, which produced an acceptable outcome in these cases of right unilateral treatment failure. This paper describes the clinical outcome, electrophysiological characteristics (impedence, estimated seizure threshold, and change in threshold), and the degree to which stimuli exceeded threshold in the responder and nonresponder groups. Responders had lower seizure thresholds and longer seizures than nonresponders. In comparison with nonresponders, responders showed trends toward greater impedance and treatment at a somewhat greater degree above threshold during the first few treatments. Threshold change with treatment was found not to be related to clinical outcome. Early identification of patients likely to respond to low-dose right unilateral ECT, together with the avoidance of benzodiazepine prescription during ECT, may permit many patients to receive low-dose right unilateral ECT successfully and with a minimum of cognitive impairment.

How long does it take for antidepressant therapies to act?

OBJECTIVE

To review the proposition that antidepressants have a delayed onset of action by employing measurement and analytic strategies that overcome problems confounding interpretation of many efficacy studies.

METHOD

A subset of patients was recruited to the longitudinal component of the Australasian database study, was assessed at baseline, and then completed measures of depression and anxiety when treatment commenced, and every 3 days over the next 4 weeks. The trajectories of defined 4-week outcome responders and non-responders were compared.

RESULTS

Both groups showed a similar decrease in depression (and anxiety) over the first 3 days. A clear trend break then occurred, with little further improvement in the non-responders, as against distinct and progressive improvement in the responders. Ongoing early improvement (across days 3-6) was a strong predictor of responder status.

CONCLUSIONS

The small sample size limits firm interpretation, although distinct interpretive advantages to the study design are evident. Findings are compatible with a number of recent studies arguing against any extensive delayed onset of action for the antidepressant drugs, but argue for caution in interpreting immediate improvement as predicting likely responder status, and more for examining early and sustained improvement as such a marker.

The ictal electroencephalogram as a marker for the efficacy of electroconvulsive therapy

The question of how to define a therapeutically adequate electroconvulsive therapy (ECT) has been under discussion since the early days of ECT. Although convention has asserted a demand for minimum seizure times, the complex electrophysiological conditions involved in developing a generalized seizure make it problematic for therapeutic efficacy of ECT to be linked only with seizure duration. Within the framework of an open clinical study of 40 patients, selected parameters of the ictal electroencephalogram (EEG) have now been examined with respect to differentiation between therapeutically effective and ineffective treatments. For this purpose a rating scale covering both quantitative and qualitative features of the ictal EEG was used. Although this study recorded no correlations between seizure duration and clinical improvement, correlations were established between clinical improvement, on the one hand, and the frequency of epileptic discharges and their slowing during the spike-wave phase as well as the stereotypy of the discharge or a "stable" pattern of rhythmic spike-wave or sharp wave complexes, on the other. The results suggest that several of these EEG parameters might be combined to form a marker for therapeutically adequate ECT, and that treatment might be controlled accordingly.

Onset and time course of antidepressant action: psychopharmacological implications of a controlled trial of electroconvulsive therapy

Onset and time course of antidepressant effect were examined in 47 patients with major depressive disorder who had been randomly assigned to twice weekly bilateral, brief pulse electroconvulsive therapy plus one simulated treatment per week (ECTx2) or to a three times weekly schedule of administration (ECTx3). Rapid improvement was observed in the ECTx3 group in whom the number of real ECTs to 30% reduction on the Hamilton Depression Scale (HAM-D) was 3.2 +/- 1.90, administered over 7.3 +/- 4.43 days and to 60% reduction, 5.9 +/- 3.09 real ECTs over 13.7 +/- 7.21 days. Among the responders in both groups combined, 24.3 +/- 29.58% of the overall improvement in HAM-D was contributed by the first real ECT, 60.9 +/- 28.13% by the first four real ECTs and 91.6 +/- 25.82% by the first eight. Although 85.3% of the responders had reached 60% HAM-D improvement after eight ECTs, a clinically significant minority (14.7%) responded later in the course (ECT 9-12). However, response was predictable on the basis of symptomatic improvement (30% on the HAM-D) by the sixth real ECT. Thirty-three out of 34 responders would have been correctly identified by this criterion and only 2 out of 13 non-responders mis-identified (P < 0.000001). Once achieved, the antidepressant effect was stable, without continuation pharmacotherapy, until 1 week after the last treatment and on lithium carbonate (Li) or Li plus clomipramine for a further 3 weeks. These findings confirm the clinical impression that ECT is a rapidly effective treatment for major depression with a shorter latency than generally reported for antidepressant drugs.(ABSTRACT TRUNCATED AT 250 WORDS)