Recent Updates on Electro-Convulsive Therapy in Patients with Depression

Correlation Between ECT Quality Measures and Likelihood to Transition From Acute to Continuation and Maintenance ECT

OBJECTIVES

To evaluate the association between 3 ECT quality measures (seizure duration, Postictal Suppression Index [PSI], and heart rate response) and therapeutic compliance as indicated by transitioning from acute to continuation to maintenance phases of ECT.

METHODS

This was a retrospective chart review of patients who received ECT between July 2016 and July 2019. ECT quality measures were lagged by 1 ECT session to examine the effect of the prior session's quality measure on progressing to a higher ECT phase at the subsequent ECT session. Associations with therapeutic compliance were analyzed using mixed-effects ordinal regression and mixed-effects partial proportional odds models.

RESULTS

Seizure duration was associated with 8% higher adjusted odds of progressing to out of the acute phase (95% confidence interval [CI]: 2% to 15%, P = 0.007) and 18% higher adjusted odds of progressing to the maintenance phase (95% CI: 10% to 28%, P < 0.001); PSI was associated with 9% higher adjusted odds of progressing out of the acute phase (95% CI: 3% to 16%, P = 0.005), whereas heart rate response was not statistically associated with therapeutic compliance. Greater therapeutic compliance was also associated with bilateral electrode placement and older age.

CONCLUSIONS

Longer seizure duration was associated with greater therapeutic compliance across all ECT phases, PSI was associated with progressing out of the acute phase, and heart rate response was not associated with therapeutic compliance. Our findings assist ECT psychiatrists in optimizing ECT quality measures to promote better compliance with ECT.

Physiotherapy for patients with depression: Recent research progress

Depression, a common mental illness, seriously affects the health of individuals and has deleterious effects on society. The prevention and treatment of depression has drawn the attention of many researchers and has become an important social issue. The treatment strategies for depression include drugs, psychotherapy, and physiotherapy. Drug therapy is ineffective in some patients and psychotherapy has treatment limitations. As a reliable adjuvant therapy, physiotherapy compensates for the shortcomings of drug and psychotherapy and effectively reduces the disease recurrence rate. Physiotherapy is more scientific and rigorous, its methods are diverse, and to a certain extent, provides more choices for the treatment of depression. Physiotherapy can relieve symptoms in many ways, such as by improving the levels of neurobiochemical molecules, inhibiting the inflammatory response, regulating the neuroendocrine system, and increasing neuroplasticity. Physiotherapy has biological effects similar to those of antidepressants and may produce a superimposed impact when combined with other treatments. This article summarizes the findings on the use of physiotherapy to treat patients with depression over the past five years. It also discusses several methods of physiotherapy for treating depression from the aspects of clinical effect, mechanism of action, and disadvantages, thereby serving as a reference for the in-depth development of physiotherapy research.

Changes in Adipokine, Resitin, and BDNF Concentrations in Treatment-Resistant Depression after Electroconvulsive Therapy

OBJECTIVES

One of the current challenges in psychiatry is the search for answers on how to effectively manage drug-resistant depression. The occurrence of drug resistance in patients is an indication for the use of electroconvulsive therapy (ECT). This method is highly effective and usually results in relatively quick health improvement. Despite the knowledge of how ECT works, not all of the biological pathways activated during its use have been identified. Hence, based on the neuroinflammatory hypothesis of depression, we investigated the concentration of two opposite-acting adipokines (anti-inflammatory adiponectin and proinflammatory resistin) and BDNF in antidepressant-resistant patients undergoing ECT.

METHODS

The study group comprised 52 patients hospitalized due to episodes of depression in the course of unipolar and bipolar affective disorder. The serum concentration of adipokines and BDNF was determined before and after the therapeutic intervention using an ELISA method. In the analyses, we also included comparisons considering the type of depression, sex, and achieving remission.

RESULTS

Adiponectin, resistin, and BDNF concentrations change after ECT treatment. These changes are correlated with an improvement in the severity of depressive symptoms and are more or less pronounced depending on the type of depression.

CONCLUSIONS

Although not all observed changes reach statistical significance, adipokines in particular remain exciting candidates for biomarkers in assessing the course of the disease and response to ECT treatment.

Improving mental health care in depression: A call for action

Depressive disorders have one of the highest disability-adjusted life years (DALYs) of all medical conditions, which led the European Psychiatric Association to propose a policy paper, pinpointing their unmet health care and research needs. The first part focuses on what can be currently done to improve the care of patients with depression, and then discuss future trends for research and healthcare. Through the narration of clinical cases, the different points are illustrated. The necessary political framework is formulated, to implement such changes to fundamentally improve psychiatric care. The group of European Psychiatrist Association (EPA) experts insist on the need for (1) increased awareness of mental illness in primary care settings, (2) the development of novel (biological) markers, (3) the rapid implementation of machine learning (supporting diagnostics, prognostics, and therapeutics), (4) the generalized use of electronic devices and apps into everyday treatment, (5) the development of the new generation of treatment options, such as plasticity-promoting agents, and (6) the importance of comprehensive recovery approach. At a political level, the group also proposed four priorities, the need to (1) increase the use of open science, (2) implement reasonable data protection laws, (3) establish ethical electronic health records, and (4) enable better healthcare research and saving resources.

Electroconvulsive therapy: recent advances and anesthetic considerations

PURPOSE OF REVIEW

This review summarizes the current indications and principles of ECT. Contemporary anesthetic considerations are described with a focus on the optimal use of hypnotic agents and providing ECT in pregnant patients.

RECENT FINDINGS

ECT is useful in treatment-resistant major depression, bipolar disorders, and treatment-resistant schizophrenia. It is a well tolerated treatment in pregnant patients with treatment-resistant depression. Cognitive side effects may be attenuated by using unilateral placement of scalp electrodes, fewer treatment sessions, and the use of ultrabrief pulse width of the electrical charge. All modern hypnotics can be used for induction of anesthesia for ECT but should be titrated to effect. Etomidate is superior to Propofol in regarding seizure quality. The use of Ketamine shows good seizure quality and may alleviate cognitive impairment. Providing ECT for pregnant patients may prove challenging because of logistic difficulties and the physiologic changes during pregnancy. Although representing an effective treatment option in severely ill patients, ECT is underutilized because of stigmatization and ethnic and financial disparities.

SUMMARY

ECT is effective in treating treatment-resistant psychiatric illnesses. Symptoms of cognitive impairment are the most common side effects but can be treated by modifying the technique of ECT. All modern hypnotics can be used for the induction of general anesthesia. Etomidate and Ketamine may be of special interest in patients with insufficient seizure duration. Treating pregnant patients with ECT requires a multidisciplinary approach, in order to provide a safe therapy for mother and unborn child. Stigmatization and social disparities are hindering the widespread use of ECT as an effective treatment for severely ill psychiatric patients.

Dysesthesia and Depression in Undiagnosed Alzheimer's Disease

Dysesthesia is an abnormal sensation typically described as tingling, burning, or itching. Dysesthesia may occur in the presence or absence of causative dermatologic or medical pathology. Sensory abnormalities have been well documented in patients suffering from Alzheimer's disease (AD), though reported abnormalities typically affect the olfactory, visual, and auditory systems. Research describing dysesthetic symptoms in AD is scarce. Major depressive disorder (MDD) is another phenomenon commonly associated with AD, though depressive symptoms are frequently masked by cognitive deficits. Less attention has been given to the reverse of this relationship, in which MDD masks the symptoms of AD. Here, we present a case of undiagnosed AD in a geriatric patient presenting with primary complaints of depression and dysesthesia. We then discuss the pathophysiology of dysesthesia, MDD, and AD, as well as how these entities may interact in a single patient. Lastly, we emphasize the importance of thorough history-taking and multi-specialty collaboration in the care of older adults.

Clinical Improvement in Depression and Cognitive Deficit Following Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a long-standing treatment choice for disorders such as depression when pharmacological treatments have failed. However, a major drawback of ECT is its cognitive side effects. While numerous studies have investigated the therapeutic effects of ECT and its mechanism, much less research has been conducted regarding the mechanism behind the cognitive side effects of ECT. As both clinical remission and cognitive deficits occur after ECT, it is possible that both may share a common mechanism. This review highlights studies related to ECT as well as those investigating the mechanism of its outcomes. The process underlying these effects may lie within BDNF and NMDA signaling. Edema in the astrocytes may also be responsible for the adverse cognitive effects and is mediated by metabotropic glutamate receptor 5 and the protein Homer1a.

Electroconvulsive Therapy for Treatment-Resistant Depression: Dispelling the Stigma

The current article is a comprehensive overview of electroconvulsive therapy (ECT) for treatment-resistant depression (TRD), especially with suicidality and psychosis. Common misconceptions and stigma associated with ECT are discussed. Major depressive disorder, one of the most prevalent lifetime mental disorders, is often associated with significant impairments that impacts one's ability to function. Antidepressants may be efficacious in treating depression; however, approximately one third of individuals do not respond to psychotropic medications. Therefore, other treatment options, such as ECT, must be considered for those who do not respond to medications, have psychosis, or are suicidal. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].

Frontostriatal circuitry as a target for fMRI-based neurofeedback interventions: A systematic review

Dysregulated frontostriatal circuitries are viewed as a common target for the treatment of aberrant behaviors in various psychiatric and neurological disorders. Accordingly, experimental neurofeedback paradigms have been applied to modify the frontostriatal circuitry. The human frontostriatal circuitry is topographically and functionally organized into the "limbic," the "associative," and the "motor" subsystems underlying a variety of affective, cognitive, and motor functions. We conducted a systematic review of the literature regarding functional magnetic resonance imaging-based neurofeedback studies that targeted brain activations within the frontostriatal circuitry. Seventy-nine published studies were included in our survey. We assessed the efficacy of these studies in terms of imaging findings of neurofeedback intervention as well as behavioral and clinical outcomes. Furthermore, we evaluated whether the neurofeedback targets of the studies could be assigned to the identifiable frontostriatal subsystems. The majority of studies that targeted frontostriatal circuitry functions focused on the anterior cingulate cortex, the dorsolateral prefrontal cortex, and the supplementary motor area. Only a few studies (n = 14) targeted the connectivity of the frontostriatal regions. However, post-hoc analyses of connectivity changes were reported in more cases (n = 32). Neurofeedback has been frequently used to modify brain activations within the frontostriatal circuitry. Given the regulatory mechanisms within the closed loop of the frontostriatal circuitry, the connectivity-based neurofeedback paradigms should be primarily considered for modifications of this system. The anatomical and functional organization of the frontostriatal system needs to be considered in decisions pertaining to the neurofeedback targets.

Changes in adipokine concentrations in antidepressant-resistant bipolar depression after ketamine infusion and electroconvulsive therapy

OBJECTIVES

This study attempts to assess the concentration of two opposite-acting adipokines (anti-inflammatory adiponectin and pro-inflammatory resistin) in antidepressant-resistant patients undergoing ketamine infusion (KI) and electroconvulsive therapy (ECT).

METHODS

The study group comprised 52 patients hospitalised due to episodes of depression in the course of bipolar disorders. The Hamilton depression scale was used to assess the intensity of the depression symptoms before starting therapy and one day after its completion. The serum concentration of adipokines was determined before and after the therapeutic intervention using an ELISA method.

RESULTS

Baseline adipokine levels differed between patients receiving KI and ECT therapy. Regardless of the procedure used, these levels changed after treatment, with the nature of these changes being different. In the case of KI, the adiponectin levels increased, and resistin levels decreased. In contrast, after ECT, the concentrations of both adipokines decreased. Changes in adipokine concentrations correlated with improvement in mental status, as assessed by the Hamilton Rating Scale, type of bipolar disorder, and gender.

CONCLUSIONS

Adipokines remain interesting candidate biomarkers in assessing the state and course of the disease depending on the therapeutic procedure applied. However, the relatively small study group and limited original research available for discussion justify further investigation.

High-frequency Repetitive Transcranial Magnetic Stimulation (rTMS) Accelerates onset Time of Beneficial Treating Effects and Improves Clinical Symptoms of Depression

BACKGROUND

In recent years, more and more patients with depression demonstrate suicidal intention and suicidal behavior.

OBJECTIVE

To evaluate the effectiveness of repetitive transcranial magnetic stimulation (rTMS) in treating depression with suicidal ideation.

METHODS

Eighty-nine depression patients with suicide intention were administrated drugs combined with four weeks of Active rTMS (n=40) or sham (n=49) rTMS treatment. The 24-item Hamilton Depression Rating Scale for Depression (HAMD-24) and Self-rating Idea of Suicide Scale (SIOSS) were used to evaluate suicide risk and depression severity at baseline, weeks 2 and 4. A 25% reduction in HAMD-24 score from baseline was defined as treatment response. More than a 20% reduction in HAMD-24 score from baseline within the first 2 weeks of treatment was defined as an early improvement.

RESULTS

No statistical significance was found for baseline sociodemographic and illness characteristics between the two groups (P >0.05). There was a significant difference for HAMD-24 and SIOSS scores between the two groups at weeks 2 and 4. Active rTMS group demonstrated a more significant score reduction compared to the Sham rTMS group at weeks 2 and 4. There was a significantly greater number of patients with early improvement observed in the Active rTMS group compared to those in the Sham rTMS group at weeks 2 (P <0.05). There was a significant difference in responder rates between the two groups at weeks 4 for HAMD-24 scores (P <0.05).

CONCLUSION

rTMS could accelerate the onset time of beneficial treating effects and improve clinical symptoms of depression. During the treatment course, cognitive disorder, sleep disorder, anxiety/ somatization, retardation, and hopelessness symptoms were improved dramatically, and suicidal ideation was reduced.

Anesthetic care for electroconvulsive therapy

Counselling and medication are often thought of as the only interventions for psychiatric disorders, but electroconvulsive therapy (ECT) has also been applied in clinical practice for over 80 years. ECT refers to the application of an electric stimulus through the patient’s scalp to treat psychiatric disorders such as treatment-resistant depression, catatonia, and schizophrenia. It is a safe, effective, and evidence-based therapy performed under general anesthesia with muscle relaxation. An appropriate level of anesthesia is essential for safe and successful ECT; however, little is known about this because of the limited interest from anesthesiologists. As the incidence of ECT increases, more anesthesiologists will be required to better understand the physiological changes, complications, and pharmacological actions of anesthetics and adjuvant drugs. Therefore, this review focuses on the fundamental physiological changes, management, and pharmacological actions associated with various drugs, such as anesthetics and neuromuscular blocking agents, as well as the comorbidities, indications, contraindications, and complications of using these agents as part of an ECT procedure through a literature review and our own experiences.

Inhibition of NLRP3 inflammasome-mediated neuroinflammation alleviates electroconvulsive shock-induced memory impairment via regulation of hippocampal synaptic plasticity in depressive rats

Electroconvulsive shock has been considered one of the most effective treatment modalities for major depressive disorder. The association of acute transitory neuroinflammation in the hippocampus following electroconvulsive therapy with transient learning and memory impairment limits its clinical application. Whereas the NLRP3 inflammatory pathway is deemed to serve a key role in neuroinflammatory regulation, we aimed to examine if NLRP3 inflammasome activation was linked to electroconvulsive shock (ECS)-induced neuroinflammation and cognitive deficits. The depressed rats were modeled with chronic unpredictable mild stress. Their depression-like behaviors and cognitive performance were evaluated via sucrose preference test, forced swim test, open field test, and Morris water maze test. The NLRP3 expression was determined by western blot. The hippocampal CA1 region was immunohistochemically and electron-microscopically examined, respectively, for the activation of Iba-1 positive microglia and the ultrastructure of synapses. In this work, we found that ECS induced microglial activation in the rat hippocampal CA1 region. Pharmacological inhibition of NLRP3 inflammasome with MCC950 (NLRP3 inhibitor) in vivo significantly alleviated ECS-induced spatial learning and memory impairment, partially reversed neuroinflammation, and synaptic structural plasticity in the damaged hippocampal CA1 region, and reduced synapse associated protein expression and microglial activation. It offers a potential new approach for the prevention and treatment of cognitive decline following electroconvulsive therapy.

Guidelines for the management of psychosis in the context of mood disorders

Psychotic episodes occur in a substantial proportion of patients suffering from major mood disorders (both unipolar and bipolar) at some point in their lives. The nature of these episodes is less well understood than the more common, non-psychotic periods of illness and hence their management is also less sophisticated. This is a concern because the risk of suicide is particularly high in this subtype of mood disorder and comorbidity is far more common. In some cases psychotic symptoms may be signs of a comorbid illness but the relationship of psychotic mood to other forms of psychosis and in particular its interactions with schizophrenia is poorly understood. Therefore, our targeted review draws upon extant research and our combined experience to provide clinical context and a framework for the management of these disorders in real-world practice - taking into consideration both biological and psychological interventions.

Systematic review of preservation TMS that includes continuation, maintenance, relapse-prevention, and rescue TMS

BACKGROUND

A dearth of evidence-based information exists to guide the delivery of transcranial magnetic stimulation (TMS) after a successful acute course of treatment for Major Depressive Disorder.

METHODS

To provide guidance for clinicians, existing literature focused on "preservation TMS" was systematically reviewed and synthesized. Preservation TMS was defined as TMS used to sustain a clinical response after a successful acute course of treatment and included reports using the terms maintenance, continuation, relapse prevention, or rescue TMS. The review protocol was registered on Open Science Framework and reported following PRISMA guidelines. Data were abstracted by two authors and discrepancies were resolved by a third author. Primary outcome measures focused on clinical efficacy. The evaluated studies were graded using the Levels of Evidence criteria published by the Oxford Centre for Evidence-Based Medicine.

RESULTS

The search included 536 abstracts and 16 additional papers, from which 63 full articles were screened. Data were abstracted from 30 qualifying sources (N=1,494) including 4 randomized controlled trials (one sham controlled), 14 open trials, and 12 case series. Overall, the quality of existing literature was low regarding efficacy but provided clear support for effectiveness and safety across a range of preservation TMS protocols based on mostly uncontrolled studies.

CONCLUSIONS

Existing literature suggests that preservation TMS protocols significantly vary and are mostly supported by open trials and case series. Due to a lack of effective alternatives, preservation TMS will likely be required for certain patients who respond to acute TMS therapy. More studies of preservation TMS are critically needed.

Understanding complex functional wiring patterns in major depressive disorder through brain functional connectome

Brain function relies on efficient communications between distinct brain systems. The pathology of major depressive disorder (MDD) damages functional brain networks, resulting in cognitive impairment. Here, we reviewed the associations between brain functional connectome changes and MDD pathogenesis. We also highlighted the utility of brain functional connectome for differentiating MDD from other similar psychiatric disorders, predicting recurrence and suicide attempts in MDD, and evaluating treatment responses. Converging evidence has now linked aberrant brain functional network organization in MDD to the dysregulation of neurotransmitter signaling and neuroplasticity, providing insights into the neurobiological mechanisms of the disease and antidepressant efficacy. Widespread connectome dysfunctions in MDD patients include multiple, large-scale brain networks as well as local disturbances in brain circuits associated with negative and positive valence systems and cognitive functions. Although the clinical utility of the brain functional connectome remains to be realized, recent findings provide further promise that research in this area may lead to improved diagnosis, treatments, and clinical outcomes of MDD.