Mechanism underlying the therapeutic effects of electroconvulsive therapy (ECT) on depression

Neurological Damage Measured by S-100b and Neuron-Specific Enolase in Patients Treated with Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is considered one of the most effective treatments for psychiatric disorders. ECT has proven effective in the treatment of depression, mania, catatonia and psychosis. It is presumed that seizures induced during ECT administration cause toxicity and potentially neuronal and glial cell death. A broad range of neurological disorders increase cerebrospinal fluid and serum levels of neuron-specific enolase (NSE) and S-100b protein. This study aims to investigate the effect of ECT on NSE and S-100b levels, which, together, serve as a proxy for neuronal cell damage. Serum concentrations of S-100b and NSE of adult patients who received ECT were measured by immunoluminometric analysis before and after treatment. A two-way ANOVA test was used to estimate the statistical differences in marker concentrations between the subgroups of the study population. Results: A total of 55 patients were included in the analysis: 52.73% (n = 29) were diagnosed with depression, 21.82% (n = 12) with schizophrenia or other psychosis, 16.36% (n = 9) with mania and 9.09% (n = 5) with catatonia. There were no statistically significant changes in NSE (p = 0.288) and S-100b (p = 0.243) levels. We found no evidence that ECT induced neuronal damage based on NSE and S-100b protein levels measured in the serum of patients before and after treatment.

Electroconvulsive therapy modulates loudness dependence of auditory evoked potentials: a pilot MEG study

Introduction

Electroconvulsive therapy (ECT) remains a critical intervention for treatment-resistant depression (MDD), yet its neurobiological underpinnings are not fully understood. This pilot study aims to investigate changes in loudness dependence of auditory evoked potentials (LDAEP), a proposed biomarker of serotonergic activity, in patients undergoing ECT.

Methods

High-resolution magnetoencephalography (MEG) was utilized to measure LDAEP in nine depressed patients receiving right unilateral ECT. We hypothesized that ECT would reduce the LDAEP slope, reflecting enhanced serotonergic neurotransmission. Depression severity and cognitive performance were assessed using the 24-item Hamilton Depression Rating Scale (HDRS24) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), respectively.

Results

Contrary to our hypothesis, findings indicated a significant increase in LDAEP post-ECT (t 8 = 3.17, p = .013). The increase in LDAEP was not associated with changes in depression severity or cognitive performance.

Discussion

The observed increase in LDAEP suggests a more complex interaction between ECT and neurobiological systems, rather than a direct reflection of serotonergic neurotransmission. Potential mechanisms for this increase include ECT's impact on serotonergic, dopaminergic, glutamatergic, and GABAergic receptor activity, neuroplasticity involving brain-derived neurotrophic factor (BDNF), and inflammatory modulators such as TNF-α. Our results highlight the multifaceted effects of ECT on brain function, necessitating further research to elucidate these interactions.

Recurrent Serotonin Syndrome After Ketamine-assisted Electroconvulsive Therapy: A Case Report and Review of the Literature

Serotonin (5-HT) syndrome (SS) consists of changes in mental status as well as autonomic and neuromuscular changes. Though not well understood, serotonergic pathways have been implicated in the mechanism of action of electroconvulsive therapy (ECT). Ketamine has been used as an induction agent in ECT and as therapy for treatment-resistant depression. Utilizing a case report and literature review, we explored the underlying serotonergic mechanisms of ECT and ketamine by which a syndrome of serotonin toxicity may be precipitated. We describe the case of a 72-year-old woman who developed recurrent SS on 2 occasions in similar circumstances involving the administration of ketamine for ECT. In our literature review, we found 5 cases in which SS was associated with ECT and 1 case linking ketamine to SS. There is emerging evidence that the mechanism of ECT involves 5-HT1A and 5-HT2A receptors, the same receptors that are involved in SS. ECT can transiently increase the permeability of the blood-brain barrier, leading to increased levels of antidepressants in the brain. ECT can, therefore, enhance 5-HT transmission and the likelihood of SS in the presence of serotonergic agents. The effect of ketamine on 5-HT transmission is mediated by the glutamate α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor. Ketamine increases α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid activity in the medial prefrontal cortex, which leads to downstream 5-HT release through glutamate. Through this mechanism, ketamine can increase 5-HT transmission, leading to SS. To our knowledge, this is the only case report of recurrent SS with concurrent use of ECT and ketamine. As ketamine is frequently used in ECT and many patients undergoing ECT are on serotonergic medications, it is important to recognize ketamine as a potential risk factor for SS. There is no evidence for added efficacy when combining ECT and ketamine. Thus, one should proceed with caution when combining these treatments. The burgeoning use of ketamine in ambulatory settings makes it necessary to elucidate the risks, which we discuss further. More research is needed into the mechanisms of ketamine and ECT, specifically how the combination of these treatments influence 5-HT levels.

Electroconvulsive Therapy Modulates Loudness Dependence of Auditory Evoked Potentials: A Pilot MEG Study

Electroconvulsive therapy (ECT) remains a critical intervention for treatment-resistant depression (MDD), yet its neurobiological underpinnings are not fully understood. This pilot study utilizes high-resolution magnetoencephalography (MEG) in nine depressed patients receiving right unilateral ECT, to investigate the changes in loudness dependence of auditory evoked potentials (LDAEP), a proposed biomarker of serotonergic activity, following ECT. We hypothesized that ECT would reduce the LDAEP slope, reflecting enhanced serotonergic neurotransmission. Contrary to this, our findings indicated a significant increase in LDAEP post-ECT ( t 8 = 3.17, p = .013). The increase in LDAEP was not associated with changes in depression severity or cognitive performance, as assessed by the Hamilton Depression Rating Scale (HAMD-24) and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). We discussed potential mechanisms for the observed increase, including ECT's impact on serotonergic, dopaminergic, glutamatergic, and GABAergic receptor activity, neuroplasticity involving brain-derived neurotrophic factor (BDNF), and inflammation modulators such as TNF- alpha . Our results suggest a complex interaction between ECT and these neurobiological systems, rather than a direct reflection of serotonergic neurotransmission.

Beyond the surface: analyzing etomidate and propofol as anesthetic agents in electroconvulsive therapy-A systematic review and meta-analysis of seizure duration outcomes

Background

Electroconvulsive therapy (ECT) is a widely used treatment for severe psychiatric disorders such as schizophrenia, depression, and mania. The procedure involves applying brief electrical stimulation to induce a seizure, and anesthesia is used to ensure sedation and muscle relaxation. Finding the right anesthetic agent with minimal side effects, especially on seizure duration, is crucial for optimal outcomes because seizure duration is an important factor in the effectiveness of ECT, but the anesthetic agents used can affect it.

Objective

This systematic review and meta-analysis aimed to pool the results of all relevant studies comparing the two induction agents, etomidate and propofol, for motor and electroencephalogram (EEG) seizure duration outcomes.

Methods

A comprehensive literature search was conducted in the PubMed, Medline, and Cochrane Library databases to identify the relevant articles. The primary outcome measures were motor and EEG seizure durations. Statistical power was ensured by performing heterogeneity, publication bias, sensitivity analysis, and subgroup analysis. Standard mean difference and 95% confidence intervals were calculated for continuous outcomes, and a random-effects model was used.

Results

A total of 16 studies were included in this meta-analysis, comprising 7 randomized control trials (RCTs), 7 crossover trials, and 2 cohorts. The overall motor seizure duration was statistically significantly longer with etomidate than with propofol. The overall result for EEG seizure duration was also longer with the use of etomidate over propofol and was statistically significant. In addition, subgrouping was performed based on the study design for both outcomes, which showed insignificant results in the cohort's subgroup for both outcomes, while the RCTs and crossover subgroups supported the overall results. Heterogeneity was assessed through subgrouping and sensitivity analysis.

Conclusion

Our meta-analysis found that etomidate is superior to propofol in terms of motor and EEG seizure duration in ECT, implying potentially better efficacy. Hence, etomidate should be considered the preferred induction agent in ECT, but larger studies are needed to further validate our findings.

Electroconvulsive Therapy: Mechanisms of Action, Clinical Considerations, and Future Directions

LEARNING OBJECTIVES

• Outline and discuss the fundamental physiologic, cellular, and molecular mechanisms of ECT to devise strategies to optimize therapeutic outcomes• Summarize the overview of ECT, its efficacy in treating depression, the known effects on cognition, evidence of mechanisms, and future directions.

ABSTRACT

Electroconvulsive therapy (ECT) is the most effective treatment for a variety of psychiatric illnesses, including treatment-resistant depression, bipolar depression, mania, catatonia, and clozapine-resistant schizophrenia. ECT is a medical and psychiatric procedure whereby electrical current is delivered to the brain under general anesthesia to induce a generalized seizure. ECT has evolved a great deal since the 1930s. Though it has been optimized for safety and to reduce adverse effects on cognition, issues persist. There is a need to understand fundamental physiologic, cellular, and molecular mechanisms of ECT to devise strategies to optimize therapeutic outcomes. Clinical trials that set out to adjust parameters, electrode placement, adjunctive medications, and patient selection are critical steps towards the goal of improving outcomes with ECT. This narrative review provides an overview of ECT, its efficacy in treating depression, its known effects on cognition, evidence of its mechanisms, and future directions.

ECT on a world map - a narrative review of the use of electroconvulsive therapy and its frequency in the world

Introduction: Since implementation, electroconvulsive therapy has remained very effective treatment in psychiatry. The aim of this study is to present the differences in its use in medical practice around the world. The range of diseases in which ECT is most commonly used and the frequency of its use in different countries were compared with special attention to the differences between highly and poorly developed countries.

Material and method: Review of literature by searching PubMed and Google Scholar databases using the keywords: indications of ECT, frequency of ECT use for papers published from 1991 to 2021.

Results: Among the diseases for which electroconvulsive therapy is used worldwide, major depression dominates, while in Asia and Africa this therapy is used in schizophrenia. In Latin America it is used primarily for schizophrenia and bipolar disorder. In Poland, it is used for depression, bipolar disorder, and fewer for schizophrenia. The highest rate of people treated with therapy per 100,000 population is found in countries such as the USA (51), Canada (23.2-25.6), Australia (37.85), Sweden (41), Finland (23), Slovakia (29.2), Estonia (27.8) and Belgium (47).

Conclusions: There is a relationship between the range of diseases most frequently treated with ECT, the frequency of use and the level of country development. In the high developed countries, ECT is used mainly in major depression, in less developed countries more frequent treatment of schizophrenia may be determined by the high cost of medications and limited availability of hospital beds. The highest rates of use of this therapy are found in more developed countries.

Role of central serotonin and noradrenaline interactions in the antidepressants' action: Electrophysiological and neurochemical evidence

The development of antidepressant drugs, in the last 6 decades, has been associated with theories based on a deficiency of serotonin (5-HT) and/or noradrenaline (NA) systems. Although the pathophysiology of major depression (MD) is not fully understood, numerous investigations have suggested that treatments with various classes of antidepressant drugs may lead to an enhanced 5-HT and/or adapted NA neurotransmissions. In this review, particular morpho-physiological aspects of these systems are first considered. Second, principal features of central 5-HT/NA interactions are examined. In this regard, the effects of the acute and sustained antidepressant administrations on these systems are discussed. Finally, future directions including novel therapeutic strategies are proposed.

Ryanodine receptors are involved in the improvement of depression-like behaviors through electroconvulsive shock in stressed mice

BACKGROUND

Electroconvulsive therapy (ECT) is effective for treating depression. However, the mechanisms underlying the antidepressant effects of ECT remain unknown. Depressed patients exhibit abnormal Ca²⁺ kinetics. Early stages of the intracellular Ca²⁺ signaling pathway involve the release of Ca²⁺ from the endoplasmic reticulum (ER) via Ca²⁺ release channels.

OBJECTIVE

We considered that depression may be improved via ECT-induced normalization of intracellular Ca²⁺ regulation through the Ca²⁺ release channels. The current study aimed to investigate the effects of ECT on two Ca²⁺ release channels, ryanodine receptors (RyRs) and inositol 1,4,5-trisphosphate receptors (IP₃Rs).

METHODS

A mouse depression-like model subjected to water immersion with restraint stress was administered electroconvulsive shock (ECS) therapy. Their depression-like status was behaviorally and histologically assessed using forced swimming tests, novelty-suppressed feeding tests, and by evaluating neurogenesis in the hippocampal dentate gyrus, respectively. A RyRs blocker, dantrolene, was administered prior to ECS, and the changes in depression-like conditions were examined.

RESULTS

The protein expressions of RyR1 and RyR3 significantly increased in the hippocampus of the mouse model with depression-like symptoms. This increase was attenuated as depression-like symptoms were reduced due to ECS application. However, pre-injection with dantrolene reduced the antidepressant effects of ECS.

CONCLUSIONS

A significant increase in RyRs expression in a depression-like state and exacerbation of depression-like symptoms by RyRs inhibitors may be caused by RyRs dysfunction, suggesting overexpression of RyRs is a compensatory effect. Normalization of RyRs expression levels by ECS suggests that ECT normalizes the Ca²⁺ release via RyRs. Thus, normalizing the function of RyRs may play an important role in the therapeutic effect of ECT.

Resting state functional connectivity predictors of treatment response to electroconvulsive therapy in depression

There is increasing focus on use of resting-state functional connectivity (RSFC) analyses to subtype depression and to predict treatment response. To date, identification of RSFC patterns associated with response to electroconvulsive therapy (ECT) remain limited, and focused on interactions between dorsal prefrontal and regions of the limbic or default-mode networks. Deficits in visual processing are reported in depression, however, RSFC with or within the visual network have not been explored in recent models of depression. Here, we support prior studies showing in a sample of 18 patients with depression that connectivity between dorsal prefrontal and regions of the limbic and default-mode networks serves as a significant predictor. In addition, however, we demonstrate that including visual connectivity measures greatly increases predictive power of the RSFC algorithm (>80% accuracy of remission). These exploratory results encourage further investigation into visual dysfunction in depression, and use of RSFC algorithms incorporating the visual network in prediction of response to both ECT and transcranial magnetic stimulation (TMS), offering a new framework for the development of RSFC-guided TMS interventions in depression.

Intermittent living; the use of ancient challenges as a vaccine against the deleterious effects of modern life - A hypothesis

Chronic non-communicable diseases (CNCD) are the leading cause of mortality in developed countries. They ensue from the sum of modern anthropogenic risk factors, including high calorie nutrition, malnutrition, sedentary lifestyle, social stress, environmental toxins, politics and economic factors. Many of these factors are beyond the span of control of individuals, suggesting that CNCD are inevitable. However, various studies, ours included, show that the use of intermittent challenges with hormetic effects improve subjective and objective wellbeing of individuals with CNCD, while having favourable effects on immunological, metabolic and behavioural indices. Intermittent cold, heat, fasting and hypoxia, together with phytochemicals in multiple food products, have widespread influence on many pathways related with overall health. Until recently, most of the employed challenges with hormetic effects belonged to the usual transient live experiences of our ancestors. Our hypothesis; we conclude that, whereas the total inflammatory load of multi-metabolic and psychological risk factors causes low grade inflammation and aging, the use of intermittent challenges, united in a 7-10 days lasting hormetic intervention, might serve as a vaccine against the deleterious effects of chronic low grade inflammation and it's metabolic and (premature) aging consequences.

Effects of Psychotropic Drugs on Seizure Threshold during Electroconvulsive Therapy

OBJECTIVE

To analyze the relationship between seizure threshold (ST) and psychotropic drugs in patients treated with ECT.

METHODS

We examined clinical data from 43 patients. ST was titrated at each treatment session. We examined associations between ST and psychotropic drugs using multivariate correlation analyses. Data are presented as initial ST, the difference in ST between the first and 10th sessions (ΔST_10th), and the mean difference in ST between the first and last sessions (mean ΔST_last).

RESULTS

Multivariate regression analyses showed associations between initial ST and the total chlorpromazine-equivalent dose of antipsychotics (β=0.363, p<0.05). The total fluoxetine-equivalent dose of antidepressants was associated with ΔST_10th (β=0.486, p<0.01) and mean ΔST_last (β=0.472, p<0.01).

CONCLUSION

Our study elucidated possible effects of psychotropic drugs on ST shifts. Larger doses of antipsychotics were associated with higher initial ST, whereas higher doses of antidepressants were associated with stronger shifts in ST.

Cold water swimming pretreatment reduces cognitive deficits in a rat model of traumatic brain injury

A moderate stress such as cold water swimming can raise the tolerance of the body to potentially injurious events. However, little is known about the mechanism of beneficial effects induced by moderate stress. In this study, we used a classic rat model of traumatic brain injury to test the hypothesis that cold water swimming preconditioning improved the recovery of cognitive functions and explored the mechanisms. Results showed that after traumatic brain injury, pre-conditioned rats (cold water swimming for 3 minutes at 4°C) spent a significantly higher percent of times in the goal quadrant of cold water swim, and escape latencies were shorter than for non-pretreated rats. The number of circulating endothelial progenitor cells was significantly higher in pre-conditioned rats than those without pretreatment at 0, 3, 6 and 24 hours after traumatic brain injury. Immunohistochemical staining and Von Willebrand factor staining demonstrated that the number of CD34⁺ stem cells and new blood vessels in the injured hippocampus tissue increased significantly in pre-conditioned rats. These data suggest that pretreatment with cold water swimming could promote the proliferation of endothelial progenitor cells and angiogenesis in the peripheral blood and hippocampus. It also ameliorated cognitive deficits caused by experimental traumatic brain injury.

Variations in myo-inositol in fronto-limbic regions and clinical response to electroconvulsive therapy in major depression

Though electroconvulsive therapy (ECT) is an established treatment for severe depression, the neurobiological factors accounting for the clinical effects of ECT are largely unknown. Myo-inositol, a neurometabolite linked with glial activity, is reported as reduced in fronto-limbic regions in patients with depression. Whether changes in myo-inositol relate to the antidepressant effects of ECT is unknown. Using magnetic resonance spectroscopy ((1)H-MRS), we measured dorsomedial anterior cingulate cortex (dmACC) and left and right hippocampal myo-inositol in 50 ECT patients (mean age: 43.78, 14 SD) and 33 controls (mean age: 39.33, 12 SD) to determine cross sectional effects of diagnosis and longitudinal effects of ECT. Patients were scanned prior to treatment, after the second ECT and at completion of the ECT index series. Controls were scanned twice at intervals corresponding to patients' baseline and end of treatment scans. Myo-inositol increased over the course of ECT in the dmACC (p = 0.042). A significant hemisphere by clinical response effect was observed for the hippocampus (p = 0.003) where decreased myo-inositol related to symptom improvement in the left hippocampus. Cross-sectional differences between patients and controls at baseline were not detected. Changes in myo-inositol observed in the dmACC in association with ECT and in the hippocampus in association with ECT-related clinical response suggest the mechanisms of ECT could include gliogenesis or a reversal of gliosis that differentially affect dorsal and ventral limbic regions. Change in dmACC myo-inositol diverged from control values with ECT suggesting compensation, while hippocampal change suggested normalization.

Serotonin syndrome after electroconvulsive therapy in a patient on trazodone, bupropion, and quetiapine: a case report

BACKGROUND

Serotonin syndrome is a potentially fatal complication that usually occurs in the combination use of several serotonergic agents. We presented a patient with major depressive disorder under the treatment of bupropion, trazodone, and quetiapine. Serotonin syndrome developed soon after she received the first session of electroconvulsive therapy (ECT).

METHOD

This study is a case report.

RESULTS

A 70-year-old female with major depressive disorder developed serotonin syndrome after the first session of ECT in combination with bupropion, trazodone, and quetiapine. Serotonin syndrome did not reappear in the subsequent ECT treatment while in the treatment with different therapeutic agents.

CONCLUSIONS

The superimposing effect of ECT in conjunction with serotonergic agents might contribute to the development of serotonin syndrome.

Management of psychiatric symptoms in anti-NMDAR encephalitis: a case series, literature review and future directions

Anti-NMDA receptor (NMDAR) encephalitis, formally recognized in 2007, has been increasingly identified as a significant cause of autoimmune and paraneoplastic encephalitis. Approximately 80% of the patients are females. The characteristic syndrome evolves in several stages, with approximately 70% of the patients presenting with a prodromal phase of fever, malaise, headache, upper respiratory tract symptoms, nausea, vomiting and diarrhoea. Next, typically within two weeks, patients develop psychiatric symptoms including insomnia, delusions, hyperreligiosity, paranoia, hallucinations, apathy and depression. Catatonic symptoms, seizures, abnormal movements, autonomic instability, memory deficits may also develop during the course of the disease. Presence of antibodies against the GluN1 subunit of the NMDAR in the CSF and serum confirm the diagnosis of NMDAR encephalitis, which also should prompt a thorough search for an underlying tumor. Age, gender, and ethnicity may all play a role, as black females older than 18 years of age have an increased likelihood of an underlying tumor. Treatment is focused on tumor resection and first-line immunotherapy [corticosteroids, plasma exchange, and intravenous immunoglobulin]. In non-responders, second- line immunotherapy [rituximab or cyclophosphamide or combined] is required. More than 75% of the patients recover completely or have mild sequelae, while the remaining patients end up demonstrating persistent severe disability or death. There is a paucity of literature on the management of psychiatric symptoms in this population. Given the neuropsychiatric symptoms in the relatively early phase of the illness, approximately 77 % of the patients are first evaluated by a psychiatrist. Earlier recognition of this illness is of paramount importance as prompt diagnosis and treatment can potentially improve prognosis. We describe two patients diagnosed with NMDAR encephalitis presenting with two different psychiatric manifestations. The first patient presented with psychotic mania and catatonic symptoms, while the second suffered from depression with psychotic and catatonic features refractory to psychotropic medications. We review of the use of psychotropic medications and ECT to address insomnia, agitation, psychosis, mood dysregulation and catatonia in NMDAR encephalitis.

Taurine and glutathione levels in plasma before and after ECT treatment

Taurine has been shown to be elevated in plasma and lymphocytes of depressed patients, but the level normalises after successful drug therapy. During depression, levels of glutathione (GSH) are decreased in the plasma and blood. This study was performed to examine taurine and GSH levels in depressed patients before and after electroconvulsive therapy (ECT). Fasting blood samples were collected from 23 patients before the first and after the third ECT treatment. The severity of depression was estimated with the Montgomery-Åsberg Depression Rating Scale (MADRS). We analysed GSH in blood and the levels of taurine and total GSH in plasma. After three ECTs, a significant decrease in MADRS scores was found for the entire group. Simultaneously, the decrease in the plasma taurine levels was significant for the seven responders but not for the sixteen non-responders. We observed no differences in blood or plasma GSH levels after three ECT treatments when compared to values before the therapy. Plasma taurine levels decrease significantly after three ECT treatments in patients who respond to treatment. GSH levels were not affected by ECT treatment. The results indicate that taurine may play a role in the pathophysiology of depression.

Treatment-resistant depression in adolescents: review and updates on clinical management

Treatment-resistant depression (TRD) in adolescents is prevalent and impairing. We here review the definition, prevalence, clinical significance, risk factors, and management of TRD in adolescents. Risk factors associated with TRD include characteristics of depression (severity, level of hopelessness, and suicidal ideation), psychiatric and medical comorbidities, environmental factors (family conflict, maternal depression, and history of abuse), and pharmacokinetics and other biomarkers. Management options include review of the adequacy of the initial treatment, re-assessment for the above-noted factors that might predispose to treatment resistance, switching antidepressants, and augmentation with medication or psychotherapy. Other modalities, such as electroconvulsive therapy, vagal nerve stimulation, and repetitive transcranial magnetic stimulation, are also reviewed.

Dopamine sudden depletion as a model for mixed depression

Up to date research on Bipolar Disorders' phenomenology is in keeping with early descriptions made by E. Kraëpelin regarding the overlap in clinical presentation of both manic and depressive symptoms, namely, mixed states. The latter constitute a highly prevalent and characteristic clinical presentation of Bipolar Disorders' and entail therapeutic difficulties, prognostic implications and increased suicidal risk. Notwithstanding, mixed states', more specifically mixed depression, have been underestimated and bypassed to the point where currently neither diagnostic criteria nor specific therapeutic recommendations are provided. In addition to the lack of agreement on nosography and diagnostic criteria, mixed depression is usually excluded from Bipolar Disorders' neurobiological models. Furthermore, renewed interest in the role of dopamine in Bipolar Disorders' physiopathology has left aside hypothesis that may account for the aforementioned clinical presentation. Interestingly enough, other syndromes arising from sudden dopamine depletion such as neuroleptic dysphoria or withdrawal syndromes from dopaminergic drugs, bear remarkable clinical similarities with mixed depression. These syndromes have been subject of further research and may thus provide a model for mixed states' physiopathology. Indeed, this article accounts for clinical similarities between mixed depression, neuroleptic induced dysphoria, and other behavioural syndromes arising from sudden dopamine depletion. After reviewing neurochemical basis of such syndromes we present, to the best of our knowledge, the first neurobiological hypothesis for mixed depression. Specifically, such hypothesis regards over activation symptoms as auto regulatory attempts to compensate for sudden dopaminergic depletion. This hypothesis provides with a beginning step for the neglected problem of mixed depression, a non-antithetic link between the dopaminergic hypothesis for both manic and depressive symptoms, a plausible explanation regarding inter individual variability to mixed depression susceptibility, and suggests new approaches for the development of novel treatments in which dopamine dysregulation should be targeted.

How is electrocardiogram influenced by electroconvulsive therapy in males and females?

OBJECTIVES

We aimed to investigate and compare the P duration and P dispersion (Pd) between male and female patients with a primary diagnosis of chronic schizophrenia disorder before and after the electroconvulsive therapy (ECT) period.

METHODS

We obtained electrocardiograms of 50 healthy young volunteers which included 25 female (group F, n = 25) and 25 male patients (group M, n = 25). We measured minimum and maximum P wave durations (Pmin, Pmax) and Pd in milliseconds. Electrocardiography was performed before electroconvulsive therapy (ECT) and immediately after the ECT period after awakening. A 12-lead surface electrocardiogram was obtained from each subject in the supine position.

RESULTS

The post-ECT P duration was significantly longer than the pre-ECT P duration in groups F and M (P = 0.01 and P = 0.008, respectively). The post-ECT Pd was significantly longer than the pre-ECT Pd in groups F and M (P = 0.0001 in both groups). A higher correlation (r) in group M was observed between the pre-ECT Pd and post-ECT P duration than in group F (r = 0.538, P = 006 in group M; r = 0.349, P = 08 in group F). There was no significant difference between the groups regarding hemodynamics.

CONCLUSIONS

Electroconvulsive therapy in both sexes may influence atrial conduction as evidenced by the significantly prolonged Pmax and Pd in patients with a primary diagnosis of schizophrenia disorder.

Frequency of and rationales for the combined use of electroconvulsive therapy and antiepileptic drugs in Austria and the literature

Our aim was to observe the frequency of combination therapy using antiepileptic drugs (AEDs) and electroconvulsive therapy (ECT) in Austria and the literature, and to provide rationales and recommendations based on clinical and molecular properties. The responsible ECT leaders of eight Austrian departments were contacted for information about combination therapy. A computerized PubMed database search was performed and supplemented by cross-referencing from papers, review articles and psychiatric manuals. The frequency of combination therapy in Austrian departments ranges between 0 and 85.7%. In 17 studies enrolling a total of 189 patients, 87 (46.0%) patients received combination therapy. Of these 87 patients, nine (10.3%) reported adverse effects. ECT and AEDs show overlapping clinical and molecular properties. Combination therapy is an observed reality and, according to the currently available literature, feasible. A comparison of clinical and molecular properties indicates possible augmentative effects, making combination therapy a promising alternative in treatment-resistant cases. But there is still a clear need for prospective case controlled data concerning side effects, safety profiles and effectiveness until it can be recommended.

Therapeutic options for treatment-resistant depression

Treatment-resistant depression (TRD) presents major challenges for both patients and clinicians. There is no universally accepted definition of TRD, but results from the US National Institute of Mental Health's (NIMH) STAR*D (Sequenced Treatment Alternatives to Relieve Depression) programme indicate that after the failure of two treatment trials, the chances of remission decrease significantly. Several pharmacological and nonpharmacological treatments for TRD may be considered when optimized (adequate dose and duration) therapy has not produced a successful outcome and a patient is classified as resistant to treatment. Nonpharmacological strategies include psychotherapy (often in conjunction with pharmacotherapy), electroconvulsive therapy and vagus nerve stimulation. The US FDA recently approved vagus nerve stimulation as adjunctive therapy (after four prior treatment failures); however, its benefits are seen only after prolonged (up to 1 year) use. Other nonpharmacological options, such as repetitive transcranial stimulation, deep brain stimulation or psychosurgery, remain experimental and are not widely available. Pharmacological treatments of TRD can be grouped in two main categories: 'switching' or 'combining'. In the first, treatment is switched within and between classes of compounds. The benefits of switching include avoidance of polypharmacy, a narrower range of treatment-emergent adverse events and lower costs. An inherent disadvantage of any switching strategy is that partial treatment responses resulting from the initial treatment might be lost by its discontinuation in favour of another medication trial. Monotherapy switches have also been shown to have limited effectiveness in achieving remission. The advantage of combination strategies is the potential to build upon achieved improvements; they are generally recommended if partial response was achieved with the current treatment trial. Various non-antidepressant augmenting agents, such as lithium and thyroid hormones, are well studied, although not commonly used. There is also evidence of efficacy and increasing use of atypical antipsychotics in combination with antidepressants, for example, olanzapine in combination with fluoxetine (OFC) or augmentation with aripiprazole. The disadvantages of a combination strategy include multiple medications, a broader range of treatment-emergent adverse events and higher costs. Several experimental pharmaceutical treatment alternatives for TRD are also being explored in combination with antidepressants or as monotherapy. These less studied alternative compounds include pindolol, inositol, CNS stimulants, hormones, herbal supplements, omega-3 fatty acids, S-adenosyl-L-methionine, folic acid, lamotrigine, modafinil, riluzole and topiramate. In summary, despite an increasing variety of choices for the treatment of TRD, this condition remains universally undefined and represents an area of unmet medical need. There are few known approved pharmacological agents for TRD (aripiprazole and OFC) and overall outcomes remain poor. This might be an indication that depression itself is a heterogeneous condition with a great diversity of pathologies, highlighting the need for careful evaluation of individuals with depressive symptoms who are unresponsive to treatment. Clearly, more research is needed to provide clinicians with better guidance in making those treatment decisions--especially in light of accumulating evidence that the longer patients are unsuccessfully treated, the worse their long-term prognosis tends to be.

COMT val158met influence on electroconvulsive therapy response in major depression

There is strong evidence for a genetic contribution to the pathogenesis of depression, with the functional catechol-O-methyltransferase (COMT) val158met polymorphism having been suggested as a potential susceptibility factor. In the present study, the effect of COMT val158met on response to electroconvulsive therapy (ECT) was analyzed in a sample of 104 Caucasian patients (f = 71, m = 33) with pharmacologically treatment-resistant Major Depression. The higher active COMT 158val allele was found to be associated with (1) higher pre-ECT severity of depression and (2) better treatment response to ECT particularly regarding the core symptoms of depression as well as sleep-related symptoms. These findings were restricted to the female subgroup of patients. In summary, the present study supports a potentially gender-specific significant impact of COMT gene variation on electroconvulsive therapy response, with COMT 158val risk allele carriers suffering from more severe, pharmacologically less efficiently treatable depression and thus possibly deriving greater benefit from ECT in the first place.

The effects of psychotherapy on neural responses to rewards in major depression

BACKGROUND

Unipolar major depressive disorder (MDD) is characterized by anomalous neurobiological responses to pleasant stimuli, a pattern that may be linked to symptoms of anhedonia. However, the potential for psychotherapy to normalize neurobiological responses to pleasant stimuli has not been evaluated.

METHODS

Twelve adults with and 15 adults without MDD participated in two identical functional magnetic resonance imaging scans that used a Wheel of Fortune task. Between scans, MDD outpatients received Behavioral Activation Therapy for Depression, a psychotherapy modality designed to increase engagement with rewarding stimuli and reduce avoidance behaviors.

RESULTS

Seventy-five percent of adults with MDD were treatment responders, achieving post-treatment Hamilton Rating Scale for Depression score of six or below. Relative to changes in brain function in the matched nondepressed group, psychotherapy resulted in functional changes in structures that mediate responses to rewards, including the paracingulate gyrus during reward selection, the right caudate nucleus (i.e., the dorsal striatum), during reward anticipation, and the paracingulate and orbital frontal gyri during reward feedback. There was no effect of diagnostic status or psychotherapy on in-scanner task-related behavioral responses.

CONCLUSIONS

Behavioral Activation Therapy for Depression, a psychotherapy modality designed to increase engagement with rewarding stimuli and reduce avoidance behaviors, results in improved functioning of unique reward structures during different temporal phases of responses to pleasurable stimuli, including the dorsal striatum during reward anticipation.

Psychiatric morbidity following electrical injury and its effects on cognitive functioning

OBJECTIVE

This study examines the prevalence of psychiatric morbidity in a large sample of electrical injury (EI) patients in three phases of recovery and its effects on cognitive functioning.

METHODS

Eight-six self-referred EI patients received psychiatric and neuropsychological evaluations. Descriptive statistics were conducted to examine the prevalence of psychiatric morbidity. Polytomous logistic regression was used to identify predictors of psychiatric diagnosis. Between-subjects analysis of variances (ANOVA) was conducted to examine the effects of psychiatric morbidity on cognitive functioning.

RESULTS

Seventy-eight percent of subjects warranted a psychiatric diagnosis. Long-term patients compared to acute patients were more likely to be diagnosed with two diagnoses than not having any diagnosis (OR=14.30, 95% CI 1.40-38.71). Patients with two diagnoses performed worse than both patients with a single or no diagnosis on all cognitive outcome measures (P<.05). Voltage level, chronic pain and litigation status did not predict psychiatric morbidity.

CONCLUSIONS

Psychiatric difficulties commonly emerge and persist following EI. EI patients with psychiatric conditions exhibited poorer cognitive performance as compared to EI patients with no post-injury psychiatric difficulties. Health care professionals need to devote careful attention to psychiatric and cognitive status when treating survivors of EI.

Catechol-O-methyltransferase (COMT) polymorphisms predict treatment response in electroconvulsive therapy

Several lines of evidence suggest that catechol-O-methyltransferase (COMT) may be associated with treatment response in depression. We conducted a study on 119 patients with treatment-refractory depression admitted consecutively for electroconvulsive therapy (ECT). The COMT high/high genotype leads to a higher enzyme activity and thus lowers dopaminergic activity in the prefrontal cortex. In the present sample, those homozygous to high-active allele of COMT responded significantly more frequently to ECT.

Anästhesiologische Aspekte bei Elektrokrampftherapie

Electroconvulsive therapy (ECT) is used in the therapy of severe psychiatric disorders. The treatment, in which a generalized epileptic seizure is provoked by electrical stimulation of the brain, is performed under anaesthesia and muscle relaxation. Considering careful previous clinical examination and anaesthesiological and internal contraindications, ECT is a safe form of treatment. The following review is intended to familiarize with ECT and to provide advice for the anaesthesiological management.

Region-specific transcriptional changes following the three antidepressant treatments electro convulsive therapy, sleep deprivation and fluoxetine

The significant proportion of depressed patients that are resistant to monoaminergic drug therapy and the slow onset of therapeutic effects of the selective serotonin reuptake inhibitors (SSRIs)/serotonin/noradrenaline reuptake inhibitors (SNRIs) are two major reasons for the sustained search for new antidepressants. In an attempt to identify common underlying mechanisms for fast- and slow-acting antidepressant modalities, we have examined the transcriptional changes in seven different brain regions of the rat brain induced by three clinically effective antidepressant treatments: electro convulsive therapy (ECT), sleep deprivation (SD), and fluoxetine (FLX), the most commonly used slow-onset antidepressant. Each of these antidepressant treatments was applied with the same regimen known to have clinical efficacy: 2 days of ECT (four sessions per day), 24 h of SD, and 14 days of daily treatment of FLX, respectively. Transcriptional changes were evaluated on RNA extracted from seven different brain regions using the Affymetrix rat genome microarray 230 2.0. The gene chip data were validated using in situ hybridization or autoradiography for selected genes. The major findings of the study are: 1. The transcriptional changes induced by SD, ECT and SSRI display a regionally specific distribution distinct to each treatment. 2. The fast-onset, short-lived antidepressant treatments ECT and SD evoked transcriptional changes primarily in the catecholaminergic system, whereas the slow-onset antidepressant FLX treatment evoked transcriptional changes in the serotonergic system. 3. ECT and SD affect in a similar manner the same brain regions, primarily the locus coeruleus, whereas the effects of FLX were primarily in the dorsal raphe and hypothalamus, suggesting that both different regions and pathways account for fast onset but short lasting effects as compared to slow-onset but long-lasting effects. However, the similarity between effects of ECT and SD is somewhat confounded by the fact that the two treatments appear to regulate a number of transcripts in an opposite manner. 4. Multiple transcripts (e.g. brain-derived neurotrophic factor (BDNF), serum/glucocorticoid-regulated kinase (Sgk1)), whose level was reported to be affected by antidepressants or behavioral manipulations, were also found to be regulated by the treatments used in the present study. Several novel findings of transcriptional regulation upon one, two or all three treatments were made, for the latter we highlight homer, erg2, HSP27, the proto oncogene ret, sulfotransferase family 1A (Sult1a1), glycerol 3-phosphate dehydrogenase (GPD3), the orphan receptor G protein-coupled receptor 88 (GPR88) and a large number of expressed sequence tags (ESTs). 5. Transcripts encoding proteins involved in synaptic plasticity in the hippocampus were strongly affected by ECT and SD, but not by FLX. The novel transcripts, concomitantly regulated by several antidepressant treatments, may represent novel targets for fast onset, long-duration antidepressants.

ECT and The Youth: Catatonia in Context

Electroconvulsive therapy (ECT) has been in psychiatric practice for well over half a century, but it continues to incite controversy. However, it is regarded amongst psychiatrists as a safe and effective treatment and at times even a lifesaver. It offers a fairly swift but a time-limited response, opening up opportunities for initiation of more longer lasting treatments. The use of ECT in the youth is limited, and as such good studies are few and far between. The recent Practice Parameters by the American Academy of Child and Adolescent Psychiatry, specifically addressing ECT in adolescents, is indeed a welcome addition. Electrocovulsive therapy is as effective in the youth as it is in the adults, and the indications and contraindication are the same. The administration of ECT follows the same general principles in all age groups. One particular indication is of the use in catatonia, a motor syndrome that could occur with affective disorders, schizophrenia or medical conditions, in which it is considered to be extremely effective. The association between catatonia and autism and spectrum disorders has been noted, and in this situation, ECT is considered by some to be effective. Ethical considerations and that of capacity and informed consent are of paramount importance as are the human rights. Working in partnership with the parents/carers all the way is a must. The lack of information leaflets on ECT especially designed for young patients and their parents has to be rectified soon. Registers based on geographical health regions for those below the age of 18 will assist tremendously in epidemiological studies as well as pave the way toward more evidence-based studies that are essential.

Neuropsychological changes following electrical injury

The clinical presentation of electrical injury commonly involves physical, cognitive, and emotional complaints. Neuropsychological studies, including case reports, have indicated that electrical injury (EI) survivors may experience a broad range of impaired neuropsychological functions, although this has not been clarified through controlled investigation. In this study, we describe the neuropsychological test findings in a series of 29 EI patients carefully screened and matched to a group of 29 demographically similar healthy electricians. Participants were matched by their estimated premorbid intellectual ability. Multivariate analysis of variance was used to assess group differences in the following neuropsychological domains: attention and mental speed, working memory, verbal memory, visual memory, and motor skills. EI patients performed significantly worse on composite measures of attention/mental speed and motor skills, which could not be explained by demographic differences, injury parameters, litigation status, or mood disturbance. Results suggest that cognitive changes do occur in patients suffering from electrical injury.

Effect of repeated administration of paroxetine and electroconvulsive shock on the proliferative response of lymphocytes and the synthesis of nitric oxide by macrophages in rats

OBJECTIVES

We sought to determine whether chronic administration of paroxetine and electroconvulsive shock (ECS), given separately or jointly, changes the proliferative response of T and B lymphocytes stimulated by mitogens and affect the production of nitric oxide (NO) by peritoneal macrophages.

METHODS

The experiment was conducted on male Wistar rats receiving treatment once daily for 12 consecutive days. Control animals were injected intraperitoneally (ip) with sterile distilled water (2 mL/kg) and were subjected to sham ECS. Paroxetine was administered ip in a dose of 10 mg/kg of body weight. ECS (150 mA, 50 Hz, 0.5 seconds) was delivered through ear clips. For combined treatment, paroxetine was given 30 minutes before ECS. The rats were killed 24 hours after the last treatment. Then, the proliferative response of splenocytes was induced by concanavalin A (Con A), lipopolysaccharide (LPS), or pokeweed mitogen and those of thymocytes by Con A and was later assessed by a standard [H]-thymidine incorporation assay. The spontaneous or induced (with LPS) NO synthesis in peritoneal macrophages was assessed as nitrite accumulation in 24-hour culture supernatants using the Griess reaction.

RESULTS

Only chronic treatment with ECS alone significantly increased the proliferative response of splenocytes to stimulation with Con A or LPS. The response of thymocytes was not changed in any group tested. Both the spontaneous NO synthesis and that induced with LPS in macrophages were significantly decreased only in rats receiving ECS.

CONCLUSIONS

We suggest that the ECS-induced suppression of NO synthesis by macrophages, resulting from the noradrenergic component of ECS action, may be responsible for the enhanced proliferative response of lymphocytes. Our data are in line with the results of other authors indicating that paroxetine and/or ECS modulate the immune system indirectly via the neuroendocrine system. The relatively high efficacy of ECS in the therapy for depression may be attributable to the ECS-evoked long-lasting changes in the immune system, which supports the macrophage theory of depression.

Differential effects of the novel antidepressant agomelatine (S 20098) versus fluoxetine on 5-HT1A receptors in the rat brain

Agomelatine (S 20098) is a novel antidepressant drug with melatonin receptor agonist and 5-HT(2C) receptor antagonist properties, but actual mechanisms underlying its antidepressant action are unknown. Because functional desensitization of 5-HT(1A) autoreceptors in the dorsal raphe nucleus (DRN) occurs after chronic administration of several classes of antidepressants, we investigated whether this adaptive change could also be induced by agomelatine. Neither acute nor chronic treatment with agomelatine (10 mg/kg i.p. for 14 days or 50 mg/kg i.p. for 21 days) changed the density of 5-HT(1A) receptors and their coupling with G proteins in the DRN and the hippocampus in rats. Moreover, these treatments did not affect the basal electrophysiological characteristics and the responses to 5-HT(1A) receptor stimulation of DRN and hippocampal neurons in brain slices. Parallel experiments with melatonin (10 mg/kg i.p. for 14 days) and fluoxetine (5 mg/kg i.p. for 14 days) as reference compounds showed that the former was unable to affect 5-HT(1A) receptors whereas the latter decreased both the 5-HT(1A) receptor-mediated [(35)S]GTP-gamma-S binding and the potency of ipsapirone, a 5-HT(1A) receptor agonist, to inhibit neuronal firing in the DRN. These data indicate that the antidepressant action of agomelatine is not mediated through the same mechanisms as SSRIs or tricyclics.

Shared mechanisms of antidepressant and antiepileptic treatments: drugs and devices

Many treatments for the epilepsies and affective disorder share the properties of seizure suppression and mood stabilization. Moreover, affective disorders and the epilepsies appear to share partially similar pathogenic mechanisms. A component of the shared predisposition appears to arise from noradrenergic and serotonergic deficits. Increasing evidence supports the hypothesis that noradrenergic and/or serotonergic elevation is a mechanism of therapeutic benefit shared by most antidepressants and many antiepileptic medications. Medication induced alterations in GABAergic, glutamatergic, and CRH (corticotropin releasing hormone) containing neurons may also contribute to the shared therapeutic properties of antidepressant and antiepileptic medications.

Successful electroconvulsive therapy in major depression with fluvoxamine-induced bruxism

A 61-year-old patient with major depression and selective serotonin reuptake inhibitor-induced bruxism was successfully treated with a course of bilateral electroconvulsive therapy. Both the depressive symptoms and bruxism completely remitted after six treatments. Possible mechanisms of this effect are discussed.

ECT of major depressed patients in relation to biological and clinical variables: a brief overview

The knowledge that spontaneous or induced convulsions can improve mental disorders has been present for several centuries. electroconvulsive therapy (ECT) has undergone fundamental changes since its introduction, and in the last 15-20 years there has been a legitimate renewal of interest for this therapy. Today the indications for use of ECT seem well codified, and its technique and practices have evolved considerably. It is now firmly established as an important and effective method of treating certain severe forms of depression. However, still very little is known about the mechanism of ECT. In this paper, first, we will give a short overview as to how far we have got concerning ECT in relation to various clinical and biological variables. Second, we will describe ECT in relation to electroencephalographic (EEG) technique and clinical outcome as well as give some proposals as to how to go on with the data analysis of EEG. In conclusion, the superior effect of ECT compared to other antidepressives in severe depression may depend on neurochemical and neurobiological cascade effects initiated by repeated treatments. Above all, ECT offers a unique experimental opportunity to study how neuromodulation of the major transmitter systems may be involved in brain dynamics and alteration of connectivity.

Electroconvulsive shock increases serotonin transporter in the rat frontal cortex

The antidepressive action of electroconvulsive shock (ECS) is thought to involve the alteration in serotonin (5-HT) neurotransmission, including the increase in 5-HT release and uptake. In our previous study, 5-HT transporter (5-HTT) mRNA expression was decreased after single and repetitive ECS in rat raphe nucleus. In the present study, we investigated the effects of single and repetitive ECS on the protein levels of 5-HTT in the frontal cortex, hippocampus and raphe nucleus of rat brain using quantitative Western blot analysis. Single ECS did not alter 5-HTT protein expression in any brain regions examined. Repetitive ECS stably increased 5-HTT protein in the frontal cortex, but not in the hippocampus and raphe nucleus. Because ECS is known to facilitate the release of neurotransmitters, our results suggest that the increased 5-HTT protein expression in the frontal cortex might be a compensatory change against the enhanced 5-HT release by ECS in presynaptic terminals.

Electroconvulsive shock regulates serotonin transporter mRNA expression in rat raphe nucleus

The antidepressive actions of electroconvulsive shock (ECS) therapy are considered to involve altered neurotransmission of serotonin. In this study, we investigated the effects of acute and chronic ECS on 5-hydroxytryptamine (5-HT) transporter mRNA expression in rat raphe nucleus. We found that serotonin transporter (5-HTT) mRNA expression was decreased in 9 and 24 h after acute ECS and in 3, 9, 24 h and 2 weeks after chronic ECS in rat raphe nucleus. We presume that the adaptive change in 5-HTT mRNA expression is possibly related to the therapeutic efficacy of electroconvulsive therapy (ECT) on medication-resistant depression.