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Sackeim HA, Aaronson ST, Bunker MT, Conway CR, George MS, McAlister-Williams RH, Prudic J, Thase ME, Young AH, Rush AJ. Update on the assessment of resistance to antidepressant treatment: Rationale for the Antidepressant Treatment History Form: Short Form-2 (ATHF-SF2). J Psychiatr Res 2024; 176:325-337. [PMID: 38917723 DOI: 10.1016/j.jpsychires.2024.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 04/09/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024]
Abstract
All definitions of treatment-resistant depression (TRD) require that patients have experienced insufficient benefit from one or more adequate antidepressant trials. Thus, identifying "failed, adequate trials" is key to the assessment of TRD. The Antidepressant Treatment History Form (ATHF) was one of the first and most widely used instruments that provided objective criteria in making these assessments. The original ATHF was updated in 2018 to the ATHF-SF, changing to a checklist format for scoring, and including specific pharmacotherapy, brain stimulation, and psychotherapy interventions as potentially adequate antidepressant treatments. The ATHF-SF2, presented here, is based on the consensus of the ATHF workgroup about the novel interventions introduced since the last revision and which should/should not be considered effective treatments for major depressive episodes. This document describes the rationale for these choices and, for each intervention, the minimal criteria for determining the adequacy of treatment administration. The Supplementary Material that accompanies this article provide the Scoring Checklist, Data Collection Forms (current episode and composite of previous episodes), and Instruction Manual for the ATHF-SF2.
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Affiliation(s)
- Harold A Sackeim
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, USA.
| | - Scott T Aaronson
- Sheppard Pratt Health System and Department of Psychiatry, University of Maryland, Baltimore, MD, USA
| | | | - Charles R Conway
- Department of Psychiatry, Washington University, St. Louis, MO, USA
| | - Mark S George
- Departments of Psychiatry,Neurology,and Neuroscience, Medical University of South Carolina and Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - R Hamish McAlister-Williams
- Northern Centre for Mood Disorders, Translational and Clinical Research Institute, Newcastle University, UK; Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Joan Prudic
- New York State Psychiatric Institute and Department of Psychiatry, Columbia University, New York, NY, USA
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, UK
| | - A John Rush
- Duke-NUS Medical School, Singapore; Duke University, Durham, NC, USA; Texas Tech University, Permian Basin, TX, USA
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Le Droguene E, Bulteau S, Deschamps T, Thomas-Ollivier V, Brichant-Petitjean C, Guitteny M, Laurin A, Sauvaget A. Dynamics of Depressive and Psychomotor Symptoms During Electroconvulsive Therapy in Older Depressive Patients: A Case Series. J ECT 2023; 39:255-262. [PMID: 37310091 DOI: 10.1097/yct.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) is an effective treatment for patients experiencing a major depressive episode, especially older ones. Identification of specific responses within early ECT sessions remains an issue of debate, however. Hence, this pilot study prospectively examined the outcome in terms of depressive signs, symptom by symptom, throughout a course of ECT, concentrating particularly on psychomotor retardation symptoms. METHODS Nine patients were clinically evaluated several times during the ECT course, before the first session and then weekly (over 3-6 weeks, according to their evolution), by completing the Montgomery-Åsberg Depression Rating Scale (MADRS), the Mini-Mental State Examination test, and the French Retardation Rating Scale for Depression for assessing the severity of psychomotor retardation. RESULTS Nonparametric Friedman tests showed significant positive changes in mood disorders during ECT in older depressive patients (mean, -27.3% of initial MADRS total score). Fast improvement in French Retardation Rating Scale for Depression score was observed at t1 (ie, after 3-4 ECT sessions), whereas a slightly delayed improvement in the MADRS scores was found at t2 (ie, after 5-6 ECT sessions). Moreover, the scores for items linked to the motor component of psychomotor retardation (eg, gait, postural control, fatigability) were the first to significantly decrease during the first 2 weeks of the ECT course compared with the cognitive component. CONCLUSIONS Interestingly, participants' concentration on daily functional activities, their interest and fatigability, and their reported state of sadness were the first to progress, representing possible precursor signs of positive patient outcomes after ECT.
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Affiliation(s)
| | - Samuel Bulteau
- Nantes Université, CHU Nantes, INSERM, Methods in Patients-Centered Outcomes and Health Research
| | - Thibault Deschamps
- Nantes Université, CHU Nantes, Movement-Interactions-Performance, Nantes
| | | | | | - Marie Guitteny
- CHU de Nantes, Service d'Addictologie et Psychiatrie de Liaison, Nantes, France
| | - Andrew Laurin
- Nantes Université, CHU Nantes, Movement-Interactions-Performance, Nantes
| | - Anne Sauvaget
- Nantes Université, CHU Nantes, Movement-Interactions-Performance, Nantes
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Nygren A, Reutfors J, Brandt L, Bodén R, Nordenskjöld A, Tiger M. Response to electroconvulsive therapy in treatment-resistant depression: nationwide observational follow-up study. BJPsych Open 2023; 9:e35. [PMID: 36786152 PMCID: PMC9970162 DOI: 10.1192/bjo.2023.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Previous studies have not investigated response rates after electroconvulsive therapy (ECT) in patients with non-psychotic treatment-resistant depression (TRD). AIMS To assess and compare the response rate of ECT for patients with TRD and non-TRD, in a large and clinically representative patient sample. METHOD Patients aged ≥18 years, who were treated for a unipolar, non-psychotic depressive episode with at least one ECT session as part of a first-time, index ECT series between 1 January 2011 and 31 December 2017 were included from the Swedish National Quality Register for ECT. Patients who had initiated a third consecutive trial of antidepressants or add-on medications before start of ECT were classified as having TRD. Patients not meeting criteria for TRD were classified as non-TRD. The main outcome was response to ECT according to the Clinical Global Impressions - Improvement Scale (CGI-I), scored as 1 or 2 ('very much' or 'much improved' after ECT, respectively). Logistic regression was used to compare outcome measures between TRD and non-TRD, adjusting for potential confounders. RESULTS A total of 4244 patients were included. Of these, 1121 patients had TRD and 3123 patients had non-TRD. The CGI-I response rate was 65.9% in the TRD group compared with 75.9% in the non-TRD group (adjusted odds ratio 0.64, 95% CI 0.54-0.75). Older age and more severe depression were predictors of response in patients with TRD. CONCLUSIONS A clear majority of patients with TRD, as well as patients with non-TRD, responded to ECT, although the response rate was somewhat lower for TRD.
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Affiliation(s)
- Adam Nygren
- Centre for Pharmacoepidemiology, Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Sweden
| | - Johan Reutfors
- Centre for Pharmacoepidemiology, Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Sweden
| | - Lena Brandt
- Centre for Pharmacoepidemiology, Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Sweden
| | - Robert Bodén
- Department of Medical Sciences, Psychiatry, Uppsala University, Sweden
| | - Axel Nordenskjöld
- University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Sweden
| | - Mikael Tiger
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Sweden
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Su L, Zhang Y, Jia Y, Sun J, Mellor D, Yuan TF, Xu Y. Predictors of Electroconvulsive Therapy Outcome in Major Depressive Disorder. Int J Neuropsychopharmacol 2022; 26:53-60. [PMID: 36190694 PMCID: PMC9850656 DOI: 10.1093/ijnp/pyac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/24/2022] [Accepted: 10/01/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is an effective therapy for major depressive disorder (MDD) patients. However, few clinical predictors are available to predict the treatment outcome. This study aimed to characterize the response trajectories of MDD patients undergoing ECT treatment and to identify potential clinical and demographic predictors for clinical improvement. METHODS We performed a secondary analysis on data from a multicenter, randomized, blinded, controlled trial with 3 ECT modalities (bifrontal, bitemporal, unilateral). The sample consisted of 239 patients whose demographic and clinical characteristics were investigated as predictors of ECT outcomes. RESULTS The results of growth mixture modeling suggested there were 3 groups of MDD patients: a non-remit group (n = 17, 7.11%), a slow-response group (n = 182, 76.15%), and a rapid-response group (n = 40, 16.74%). Significant differences in age, education years, treatment protocol, types of medication used, Hamilton Depression Scale, Hamilton Anxiety Scale score, Mini-Mental State Examination score, and Clinical Global Impression score at baseline were observed across the groups. CONCLUSIONS MDD patients exhibited distinct and clinically relevant response trajectories to ECT. The MDD patients with more severe depression at baseline are associated with a rapid response trajectory. In contrast, MDD patients with severe symptoms and older age are related to a less response trajectory. These clinical predictors may help guide treatment selection.
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Affiliation(s)
| | | | - Yuping Jia
- Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junfeng Sun
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
| | - David Mellor
- Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China,School of Psychology, Deakin University, Melbourne, Australia
| | - Ti-Fei Yuan
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yifeng Xu
- Correspondence: Yifeng Xu, MD, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China ()
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High exposure to pharmacological treatments is associated with limited efficacy of electroconvulsive therapy in bipolar depression. Psychiatry Res 2021; 304:114169. [PMID: 34425459 DOI: 10.1016/j.psychres.2021.114169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 04/09/2021] [Accepted: 08/07/2021] [Indexed: 11/23/2022]
Abstract
Episode chronicity and medication failure are considered robust predictors of poor response to electroconvulsive therapy (ECT). In this study we explored the associations between indexes of drug exposure during current episode and outcomes of ECT in 168 bipolar depressive patients. The association between response or remission and number of previous pharmacological trials, failure of treatment with antidepressants, antipsychotics or combinations, and sum of maximum Antidepressant Treatment History Form (ATHF) scores obtained in each pharmacological class were tested. 98 patients (58%) were considered responders and 21 remitters (13%). Number of trials, number of adequate trials, ATHF sum, antidepressant-antipsychotic combination therapy failure and failure of two adequate trials were significantly negatively associated with remission. The association with ATHF sum stayed significant when controlling for episode duration and manic symptoms and survived stepwise model selection. No significant associations with response were identified. In conclusion, a history of multiple drug treatments may be linked to a greater resistance to all types of therapies, including ECT. However, we could not exclude that, at least in some patients, a prolonged exposure to pharmacological treatments may be responsible for a greater chronicity and for the presence of residual symptoms, which would explain reduced remission after ECT.
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Sahlem GL, McCall WV, Short EB, Rosenquist PB, Fox JB, Youssef NA, Manett AJ, Kerns SE, Dancy MM, McCloud L, George MS, Sackeim HA. A two-site, open-label, non-randomized trial comparing Focal Electrically-Administered Seizure Therapy (FEAST) and right unilateral ultrabrief pulse electroconvulsive therapy (RUL-UBP ECT). Brain Stimul 2020; 13:1416-1425. [PMID: 32735987 PMCID: PMC7500956 DOI: 10.1016/j.brs.2020.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Focal Electrically-Administered Seizure Therapy (FEAST) is a form of electroconvulsive therapy (ECT) that spatially focuses the electrical stimulus to initiate seizure activity in right prefrontal cortex. Two open-label non-comparative studies suggested that FEAST has reduced cognitive side effects when compared to historical data from other forms of ECT. In two different ECT clinics, we compared the efficacy and cognitive side effects of FEAST and Right Unilateral Ultrabrief Pulse (RUL-UBP) ECT. METHODS Using a non-randomized, open-label design, 39 depressed adults were recruited after referral for ECT. Twenty patients received FEAST (14 women; age 45.2 ± 12.7), and 19 received RUL-UBP ECT (16 women; age 43.2 ± 16.4). Key cognitive outcome measures were the postictal time to reorientation and the Columbia University Autobiographical Memory Interview: Short-Form (CUAMI-SF). Antidepressant effects were assessed using the Hamilton Rating Scale for Depression (HRSD24). RESULTS In the Intent-to-treat sample, a repeated measures mixed model suggested no between group difference in HRSD24 score over time (F1,35 = 0.82, p = 0.37), while the response rate favored FEAST (FEAST: 65%; RUL-UBP ECT: 57.9%), and the remission rate favored RUL-UBP ECT (FEAST: 35%; RUL-UBP ECT: 47.4%). The FEAST group had numeric superiority in average time to reorientation (FEAST: 6.6 ± 5.0 min; RUL-UBP ECT: 8.8 ± 5.8 min; Cohens d = 0.41), and CUAMI-SF consistency score (FEAST: 69.2 ± 14.2%; RUL-UBP ECT: 63.9 ± 9.9%; Cohens d = 0.43); findings that failed to meet statistical significance. CONCLUSIONS FEAST exerts similar efficacy relative to an optimal form of conventional ECT and may have milder cognitive side effects. A blinded, randomized, non-inferiority trial is needed.
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Affiliation(s)
- Gregory L Sahlem
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA.
| | - William V McCall
- Department of Psychiatry and Health Behavior, GA, USA; Medical College of Georgia, GA, USA; Augusta University, GA, USA
| | - E Baron Short
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA
| | - Peter B Rosenquist
- Department of Psychiatry and Health Behavior, GA, USA; Medical College of Georgia, GA, USA; Augusta University, GA, USA
| | - James B Fox
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA
| | - Nagy A Youssef
- Department of Psychiatry and Health Behavior, GA, USA; Medical College of Georgia, GA, USA; Augusta University, GA, USA
| | - Andrew J Manett
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA
| | - Suzanne E Kerns
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA
| | - Morgan M Dancy
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA
| | - Laryssa McCloud
- Department of Psychiatry and Health Behavior, GA, USA; Medical College of Georgia, GA, USA; Augusta University, GA, USA
| | - Mark S George
- Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, SC, USA; Ralph H. Johnson VA Medical Center, SC, USA
| | - Harold A Sackeim
- Departments of Psychiatry and Radiology, Columbia University, NY, USA
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The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An Update on Unipolar Nonpsychotic Depression. Harv Rev Psychiatry 2020; 27:33-52. [PMID: 30614886 DOI: 10.1097/hrp.0000000000000197] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The Psychopharmacology Algorithm Project at the Harvard South Shore Program presents evidence-based recommendations considering efficacy, tolerability, safety, and cost. Two previous algorithms for unipolar nonpsychotic depression were published in 1993 and 1998. New studies over the last 20 years suggest that another update is needed. METHODS The references reviewed for the previous algorithms were reevaluated, and a new literature search was conducted to identify studies that would either support or alter the previous recommendations. Other guidelines and algorithms were consulted. We considered exceptions to the main algorithm, as for pregnant women and patients with anxious distress, mixed features, or common medical and psychiatric comorbidities. SUMMARY For inpatients with severe melancholic depression and acute safety concerns, electroconvulsive therapy (or ketamine if ECT refused or ineffective) may be the first-line treatment. In the absence of an urgent indication, we recommend trialing venlafaxine, mirtazapine, or a tricyclic antidepressant. These may be augmented if necessary with lithium or T3 (triiodothyronine). For inpatients with non-melancholic depression and most depressed outpatients, sertraline, escitalopram, and bupropion are reasonable first choices. If no response, the prescriber (in collaboration with the patient) has many choices for the second trial in this algorithm because there is no clear preference based on evidence, and there are many individual patient considerations to take into account. If no response to the second medication trial, the patient is considered to have a medication treatment-resistant depression. If the patient meets criteria for the atypical features specifier, a monoamine oxidase inhibitor could be considered. If not, reconsider (for the third trial) some of the same options suggested for the second trial. Some other choices can also considered at this stage. If the patient has comorbidities such as chronic pain, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, or posttraumatic stress disorder, the depression could be secondary; evidence-based treatments for those disorders would then be recommended.
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Smith AWT, Virk S. Recurrent Suicidal Ideation During Intravenous Ketamine Treatment. Am J Ther 2020; 26:e732-e735. [PMID: 30946043 DOI: 10.1097/mjt.0000000000000886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | - Subhdeep Virk
- Ohio State University Wexner Medical Center, Columbus, OH
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Bulteau S, Guirette C, Brunelin J, Poulet E, Trojak B, Richieri R, Szekely D, Bennabi D, Yrondi A, Rotharmel M, Bougerol T, Dall’Igna G, Attal J, Benadhira R, Bouaziz N, Bubrovszky M, Calvet B, Dollfus S, Foucher J, Galvao F, Gay A, Haesebaert F, Haffen E, Jalenques I, Januel D, Jardri R, Millet B, Nathou C, Nauczyciel C, Plaze M, Rachid F, Vanelle JM, Sauvaget A. Troubles de l’humeur : quand recourir à la stimulation magnétique transcrânienne ? Presse Med 2019; 48:625-646. [DOI: 10.1016/j.lpm.2019.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 12/30/2018] [Accepted: 01/31/2019] [Indexed: 12/24/2022] Open
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10
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Sackeim HA, Aaronson ST, Bunker MT, Conway CR, Demitrack MA, George MS, Prudic J, Thase ME, Rush AJ. The assessment of resistance to antidepressant treatment: Rationale for the Antidepressant Treatment History Form: Short Form (ATHF-SF). J Psychiatr Res 2019; 113:125-136. [PMID: 30974339 DOI: 10.1016/j.jpsychires.2019.03.021] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/11/2019] [Accepted: 03/21/2019] [Indexed: 12/26/2022]
Abstract
There is considerable diversity in how treatment-resistant depression (TRD) is defined. However, every definition incorporates the concept that patients with TRD have not benefited sufficiently from one or more adequate trials of antidepressant treatment. This review examines the issues fundamental to the systematic evaluation of antidepressant treatment adequacy and resistance. These issues include the domains of interventions deemed effective in treatment of major depressive episodes (e.g., pharmacotherapy, brain stimulation, and psychotherapy), the subgroups of patients for whom distinct adequacy criteria are needed (e.g., bipolar vs. unipolar depression, psychotic vs. nonpsychotic depression), whether trials should be rated dichotomously as adequate or inadequate or on a potency continuum, whether combination and augmentation strategies require specific consideration, and the criteria used to evaluate the adequacy of treatment delivery (e.g., dose, duration), trial adherence, and clinical outcome. This review also presents the Antidepressant Treatment History Form: Short-Form (ATHF-SF), a completely revised version of an earlier instrument, and details how these fundamental issues were addressed in the ATHF-SF.
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Affiliation(s)
- Harold A Sackeim
- Departments of Psychiatry and Radiology, Columbia University, New York, NY, USA.
| | - Scott T Aaronson
- Sheppard Pratt Health System and Department of Psychiatry, University of Maryland, Baltimore, MD, USA
| | | | - Charles R Conway
- Department of Psychiatry, Washington University, St. Louis, MO, USA
| | | | - Mark S George
- Departments of Psychiatry, Neurology, and Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Joan Prudic
- New York State Psychiatric Institute and Department of Psychiatry, Columbia University, New York, NY, USA
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - A John Rush
- Duke-NUS Medical School, Singapore; Duke University, Durham, NC, USA; Texas Tech University, Permian Basin, TX, USA
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Mojtabai R. Nonremission and time to remission among remitters in major depressive disorder: Revisiting STAR*D. Depress Anxiety 2017; 34:1123-1133. [PMID: 28833903 DOI: 10.1002/da.22677] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 06/14/2017] [Accepted: 07/19/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Some individuals with major depressive disorder do not experience a remission even after one or more adequate treatment trials. In some others who experience remission, it happens at variable times. This study sought to estimate the prevalence of nonremission in a large sample of patient participating in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial and to identify correlates of nonremission and time to remission among remitters. METHODS Using data from 3,606 participants of STAR*D, the study used cure regression modeling to estimate nonremission and jointly model correlates of nonremission and time to remission among the remitters. RESULTS Overall, 14.7% of the STAR*D participants were estimated to be nonremitters. Among remitters, the rate of remission declined over time. Greater severity, poorer physical health, and poor adherence with treatments were associated with both nonremission and a longer time to remission among the remitters in multivariable analyses, whereas unemployment, not having higher education, and longer duration of current episode were uniquely associated with nonremission; whereas, treatment in specialty mental health settings, poorer mental health functioning, and greater impairment in role functioning with a longer time to remission among remitters. CONCLUSION Poor treatment adherence and poor physical health appear to be common risk factors for both nonremission and longer time to remission, highlighting the importance of integrated care models that address both medical and mental healthcare needs and interventions aimed at improving treatment adherence.
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Affiliation(s)
- Ramin Mojtabai
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
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12
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Clinical factors related to acute electroconvulsive therapy outcome for patients with major depressive disorder. Int Clin Psychopharmacol 2017; 32:127-134. [PMID: 28177952 DOI: 10.1097/yic.0000000000000167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study was to explore the significant predictors associated with electroconvulsive therapy (ECT) outcome for patients with major depressive disorder. Major depressive disorder inpatients (N=130) requiring ECT were recruited from a major psychiatric center in South Taiwan. ECT was generally performed for a maximum of 12 sessions. Symptom severity was assessed using the 17-item Hamilton Depression Rating Scale (HAMD-17) and Clinical Global Impression of Severity (CGI-S) before ECT, after every three ECT sessions, and after the last ECT. The generalized estimating equations method was used to analyze the influence of potential variables over time on the HAMD-17 and CGI-S, respectively. Fourteen patients not completing the first three sessions of ECT were excluded. The remaining 116 patients were included in the analysis. Patients with treatment-resistant depression, longer duration of the current depressive episode, and higher levels of pain were more likely to have less symptom reduction after acute treatment with ECT, irrespective of how the depressive symptoms were rated using HAMD-17 or CGI-S. To improve efficacy, earlier application of ECT and pain control should be considered during an acute course of ECT. Other clinical predictors related to ECT outcome require further investigation in future studies.
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Martits-Chalangari K, Milton A, Husain MM. Magnetic Seizure Therapy: an Evolution of Convulsive Therapy. Curr Behav Neurosci Rep 2016. [DOI: 10.1007/s40473-016-0094-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Lin CH, Chen MC, Yang WC, Lane HY. Early improvement predicts outcome of major depressive patients treated with electroconvulsive therapy. Eur Neuropsychopharmacol 2016; 26:225-233. [PMID: 26718791 DOI: 10.1016/j.euroneuro.2015.12.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 11/11/2015] [Accepted: 12/01/2015] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Ching-Hua Lin
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Chao Chen
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Cheng Yang
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
| | - Hsien-Yuan Lane
- Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan; Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan.
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Rhebergen D, Huisman A, Bouckaert F, Kho K, Kok R, Sienaert P, Spaans HP, Stek M. Older age is associated with rapid remission of depression after electroconvulsive therapy: a latent class growth analysis. Am J Geriatr Psychiatry 2015; 23:274-82. [PMID: 24951182 DOI: 10.1016/j.jagp.2014.05.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 04/28/2014] [Accepted: 05/09/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study aims to empirically identify latent course trajectories of depressive symptoms during electroconvulsive therapy (ECT) within a cohort of patients suffering from a depressive disorder and to examine putative predictors of course. METHODS Using a prospective cohort multicenter collaborative ECT design, 120 patients fulfilling the Mini International Neuropsychiatric Interview criteria for major depressive disorder and referred for ECT were selected. Ratings of the 17-item Hamilton Rating Scale for Depression (HRSD) were obtained weekly during the course of ECT. Latent class growth analysis was used to identify trajectories of course during 6-week follow-up, based on weekly total HRSD scores. Characteristics of the identified classes were examined, and putative predictors for class membership were tested. RESULTS Data-driven techniques identified distinct course trajectories during 6-week follow-up ECT treatment, consisting of "rapid remission," "moderate response," and "nonremitting" course trajectories. Remission rates were as high as 80.1% in the rapid remission class. Older age was associated with rapid remission, even after adjustment for putative confounders. CONCLUSION Our results strongly confirm the favorable outcome of ECT among elderly depressed inpatients.
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Affiliation(s)
- Didi Rhebergen
- Department of Psychiatry and the EMGO(+) Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; GGZ inGeest, Amsterdam, The Netherlands.
| | | | - Filip Bouckaert
- ECT Department, University Psychiatric Center, Catholic University Leuven, campus Kortenberg, Kortenberg, Belgium
| | - King Kho
- Parnassia, Psychiatric Institute the Hague, Clinical Center for the Elderly-ECT Department, The Hague, The Netherlands
| | - Rob Kok
- Parnassia, Psychiatric Institute the Hague, Clinical Center for the Elderly-ECT Department, The Hague, The Netherlands
| | - Pascal Sienaert
- ECT Department, University Psychiatric Center, Catholic University Leuven, campus Kortenberg, Kortenberg, Belgium
| | - Harm-Pieter Spaans
- Parnassia, Psychiatric Institute the Hague, Clinical Center for the Elderly-ECT Department, The Hague, The Netherlands
| | - Max Stek
- Department of Psychiatry and the EMGO(+) Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; GGZ inGeest, Amsterdam, The Netherlands
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Bauer M, Pfennig A, Severus E, Whybrow PC, Angst J, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders. World J Biol Psychiatry 2013; 14:334-85. [PMID: 23879318 DOI: 10.3109/15622975.2013.804195] [Citation(s) in RCA: 381] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES This 2013 update of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal has been to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. The guidelines are intended for use by all physicians seeing and treating patients with these conditions. METHODS The 2013 update was conducted by a systematic update literature search and appraisal. All recommendations were approved by the Guidelines Task Force. RESULTS This first part of the guidelines (Part 1) covers disease definition, classification, epidemiology, and course of unipolar depressive disorders, as well as the management of the acute and continuation phase treatment. It is primarily concerned with the biological treatment (including antidepressants, other psychopharmacological medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of adults. CONCLUSIONS To date, there is a variety of evidence-based antidepressant treatment options available. Nevertheless there is still a substantial proportion of patients not achieving full remission. In addition, somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated. Therefore, further high-quality informative randomized controlled trials are urgently needed.
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Affiliation(s)
- Michael Bauer
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany.
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Blumberger DM, Mulsant BH, Emeremni C, Houck P, Andreescu C, Mazumdar S, Whyte E, Rothschild AJ, Flint AJ, Meyers BS. Impact of prior pharmacotherapy on remission of psychotic depression in a randomized controlled trial. J Psychiatr Res 2011; 45:896-901. [PMID: 21300377 PMCID: PMC3419434 DOI: 10.1016/j.jpsychires.2011.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 12/20/2010] [Accepted: 01/06/2011] [Indexed: 11/26/2022]
Abstract
Having failed to respond to an adequate antidepressant treatment course predicts poorer treatment outcomes in patients with major depression. However, little is known about the impact of prior treatment on the outcome of major depression with psychotic features (MDpsy). We examined the effect of prior treatment history on the outcome of pharmacotherapy of MDpsy in patients who participated in the STOPD-PD study, a randomized, double-blind, clinical trial comparing a combination of olanzapine plus sertraline vs. olanzapine plus placebo. The strength of treatment courses received prior to randomization was classified using a validated method. A hierarchy of outcomes was hypothesized based on treatments received prior to randomization and randomized treatment. A high remission rate was observed in subjects with a history of no prior treatment or inadequate treatment who were treated with a combination of olanzapine and sertraline. A low remission rate was observed in subjects who had previously failed to respond to an antidepressant alone and who were treated with olanzapine monotherapy. A low remission rate was also observed in subjects who had previously failed to respond to a combination of an antipsychotic and an antidepressant. Similar to patients with major depression, these results emphasize the impact of prior pharmacotherapy on treatment outcomes in patients with MDpsy.
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Affiliation(s)
- Daniel M. Blumberger
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Benoit H. Mulsant
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada,Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Chetachi Emeremni
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Patricia Houck
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Carmen Andreescu
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Sati Mazumdar
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Ellen Whyte
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Anthony J. Rothschild
- University of Massachusetts Medical School and University of Massachusetts Memorial Health Care
| | - Alastair J. Flint
- University Health Network Department of Psychiatry, the Geriatric Program and Research Institute, Toronto Rehabilitation Institute, Department of Psychiatry University of Toronto
| | - Barnett S. Meyers
- Department of Psychiatry, Weill Medical College of Cornell University and New York Presbyterian Hospital - Westchester Division
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Predictors of response to ultrabrief right unilateral electroconvulsive therapy. J Affect Disord 2011; 130:192-7. [PMID: 20961620 DOI: 10.1016/j.jad.2010.09.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 09/03/2010] [Accepted: 09/15/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent trials have demonstrated clinically meaningful efficacy and minimal cognitive side effects with ultrabrief pulsewidth right unilateral (RUL) ECT. In many countries it is gradually being adopted into clinical practice and further information on predictors of response is needed. METHODS Data collected from 75 depressed patients who received ultrabrief RUL ECT in a prospective research trial were analysed for predictors of response. Mood improvement was assessed with the Montgomery-Asberg Depression Rating Scale. Improvement in unipolar versus bipolar depression was analysed. RESULTS Sixty-one percent of patients met the criteria for response and 36% met the criteria for remission. Logistic regression identified index episode duration ≥one year (OR=10.50, p=.006), fewer failed antidepressant treatments (OR=0.46, p=.003), previous ECT course (OR=7.33, p=.01), and absence of concurrent antidepressant (OR=0.09, p=.005) as predictors of response. Psychotic features (OR=7.18, p=.032) and baseline depression severity (OR=0.90, p=.017) were predictors of remission. There was a trend towards greater improvement in bipolar than unipolar depression in the first week of treatment (p=0.077). LIMITATIONS Data were obtained from a prospective but non-randomised clinical trial which was designed to evaluate efficacy rather than to examine predictors of response. Treatment decisions (concurrent medication, switching to other types of ECT) were made on clinical grounds. CONCLUSIONS This preliminary study suggests that predictors of response for ultrabrief RUL ECT are similar to those identified for other types of ECT previously studied.
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Perugi G, Medda P, Zanello S, Toni C, Cassano GB. Episode length and mixed features as predictors of ECT nonresponse in patients with medication-resistant major depression. Brain Stimul 2011; 5:18-24. [PMID: 22037132 DOI: 10.1016/j.brs.2011.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 02/04/2011] [Accepted: 02/16/2011] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES This study aimed to ascertain predictors of nonresponse to electroconvulsive therapy (ECT) in a large sample of major depressive patients resistant to pharmacologic treatment. METHODS A total of 208 depressive patients (31 with major depression [UP], 101 with bipolar disorder II [BP II], and 76 with bipolar disorder I [BP I] according to DSM-IV criteria) were included in the study and treated with bilateral ECT on a twice-a-week schedule. The patients were assessed before (baseline) and a week after the ECT course (final score) using the Hamilton Rating Scale for Depression-17 items (HAM-D-17), the Young Mania Rating Scale (YMRS), the Brief Psychiatric Rating Scale (BPRS), and the Clinical Global Improvement (CGI). Responders were defined as those patients with a reduction of at least 50% in HAM-D-17 score and a rating of 2 ("much improved") or 1 ("very much improved") in the CGI-Improvement subscale. RESULTS At the end of the ECT course, 152 patients (64%) were classified as responders and 56 patients (36%) were classified as nonresponders. On backward stepwise logistic regression, bipolar subtype (odds ratio [OR]=17.85; 95% confidence level [CL]=1.786-178.407), higher mean baseline YMRS scores (OR=1.094; 95% CL=1.025-1.166), lower mean baseline HAM-D-17 scores (OR=0.928; 95% CL=0.860-1.002), and length of current episode (OR=1.047; 95% CL=1.009-1.086) were identified as statistically significant predictors of nonresponse. CONCLUSIONS ECT was an effective treatment for approximately two-thirds of the patients with medication-resistant depression who were included in this study. ECT nonresponse was associated with bipolar subtype, presence of manic symptoms during depression, slightly less severe depressive symptomatology, and protracted duration of the episode.
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Affiliation(s)
- G Perugi
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa, Pisa, Italy.
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Sienaert P. What we have learned about electroconvulsive therapy and its relevance for the practising psychiatrist. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2011; 56:5-12. [PMID: 21324237 DOI: 10.1177/070674371105600103] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In this narrative review, the current knowledge base on the efficacy and the practice of electroconvulsive therapy (ECT) is reviewed, and its relevance for the practising psychiatrist is appreciated. In the past decade, several large-scale studies have confirmed the significant superiority of ECT in the treatment of severe and refractory psychiatric conditions, such as major depressive disorder and bipolar disorder. However, the efficacy of ECT is not reflected in current treatment algorithms, where ECT is often reserved as a last resort. However, clinical characteristics, such as the presence of psychotic symptoms, suicidality, or catatonic signs, should prompt the clinician to consider ECT earlier in the treatment course. ECT is a safe procedure, without absolute contraindications for its use. Nevertheless, patients' fears and complaints should be acknowledged, and patients should be adequately informed about expected benefits and possible risks, such as memory problems, that are generally transient. Research focusing on further minimizing memory problems, while maintaining a superior efficacy, is ongoing. Adequate continuation treatment, either pharmacotherapy or continuation ECT, after a successful ECT course is of vital importance to maintain the benefits achieved and should be the focus of future research.
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Affiliation(s)
- Pascal Sienaert
- ECT Department, University Psychiatric Center-Catholic University Leuven, campus Kortenberg, Leuvensesteenweg 517, Kortenberg, Belgium.
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Abstract
OBJECTIVE In 2001, the American Psychiatric Association's Task Force on electroconvulsive therapy (ECT) recommended that psychiatry residents should receive at least 4 hours of didactic instruction on ECT, participate in at least 10 treatments, and assist in the care of at least 3 patients receiving ECT. Residency accreditation requirements as of 2007, however, require only that training programs ensure competency in "understanding the indications and uses" of ECT. Anecdotally, training in ECT is said to vary widely between residency programs. The purpose of the study was to obtain more systematic information about ECT training. METHOD A survey was e-mailed to directors of all accredited psychiatry residency programs in the United States and Puerto Rico in early to mid 2008, requesting information regarding their didactic and clinical instruction in ECT and estimates of number of treatments provided by their institutions. RESULTS Responses were obtained from 91 training programs. Of these programs, 75% reported that some clinical exposure to ECT was required of their residents, but 37% estimated that the typical resident would participate in fewer than 10 treatments and 27% estimated that the typical resident would care for fewer than 5 patients receiving ECT. Most programs devoted less than 4 hours of lecture time to ECT. Most respondents believed that ECT was underused nationally; this perception did not differ based on the theoretical orientation of the training program. CONCLUSIONS This study suggests that resident education in ECT varies considerably between programs but is often less than that suggested by the American Psychiatric Association's Task Force.
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Heijnen WT, Birkenhäger TK, Wierdsma AI, van den Broek WW. Antidepressant pharmacotherapy failure and response to subsequent electroconvulsive therapy: a meta-analysis. J Clin Psychopharmacol 2010; 30:616-9. [PMID: 20814336 DOI: 10.1097/jcp.0b013e3181ee0f5f] [Citation(s) in RCA: 130] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Failure to respond to antidepressants probably is the most common indication for electroconvulsive therapy (ECT). The literature seems to be divided as to whether medication resistance has a negative influence on the efficacy of subsequent ECT. Therefore, we performed a systematic review to investigate the effect of previous pharmacotherapy failure on the efficacy of ECT. Relevant cohort studies were identified from systematic search of the PubMed electronic database. Seven studies were included in this meta-analysis: the overall remission rate amounts to 48.0% (281/585) for patients with and 64.9% (242/373) for patients without previous pharmacotherapy failure. An exact analysis with the Mantel-Haenszel method (fixed effect model) shows a reduced efficacy of ECT in patients that received previous pharmacotherapy (OR, 0.52; 95% confidence interval [CI], 0.39-0.69). In conclusion, the efficacy of ECT is significantly superior in patients without previous pharmacotherapy failure as compared with medication-resistant patients. Because this finding is based on observational studies, it might be caused by a confounding factor, for example, the presence of psychotic features or the duration of the index episode. Electroconvulsive therapy seems to be an effective treatment for severely depressed patients as well as for patients with previous pharmacotherapy failure.
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Affiliation(s)
- Willemijn T Heijnen
- Department of Psychiatry, Erasmus Medical Centre, 3000 CA Rotterdam, The Netherlands
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Cinar S, Oude Voshaar RC, Janzing JGE, Birkenhäger TK, Buitelaar JK, van den Broek WW. The course of depressive symptoms in unipolar depressive disorder during electroconvulsive therapy: a latent class analysis. J Affect Disord 2010; 124:141-7. [PMID: 19931917 DOI: 10.1016/j.jad.2009.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2009] [Revised: 11/01/2009] [Accepted: 11/01/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Research examining the course of depressive symptoms during electroconvulsive therapy (ECT) is relatively scarce. OBJECTIVE To classify patients according to the course of their depressive symptoms while receiving ECT. METHODS The sample consisted of 156 consecutive patients receiving ECT for unipolar depressive disorder. Depressive symptoms were measured weekly with the Montgomery-Asberg Depression Rating Scale. Latent class analysis was applied to identify distinct trajectories of symptom improvement. RESULTS We identified five classes of different trajectories (improvement rates) of depressive symptoms, i.e. fast improvement (39 patients), intermediate improvement (47 patients), slow improvement (30 patients), slow improvement with delayed onset (18 patients), and finally a trajectory with no improvement (20 patients). The course of depressive symptoms at the end of the treatment within the trajectories of intermediate improvement, slow improvement and slow improvement with delayed onset, was still improving and did not achieve a plateau. CONCLUSION The different courses of depressive symptoms during ECT probably contribute to mixed results of prediction studies of ECT outcome. Data suggest that for a large group of patients no optimal clinical endpoint can be identified, other than full remission or no improvement at all, to discontinue ECT.
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Affiliation(s)
- S Cinar
- Radboud University Nijmegen Medical Centre, Nijmegen Centre for Evidence-Based Practice, Department of Psychiatry, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Combination of pharmacotherapy with electroconvulsive therapy in prevention of depressive relapse: a pilot controlled trial. J ECT 2010; 26:104-10. [PMID: 19935091 DOI: 10.1097/yct.0b013e3181c189f7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Relapse rates after electroconvulsive therapy (ECT) remain high with standard treatments. We aimed to test the efficacy of an early administered continuation pharmacotherapy (c-pharm early) strategy in prevention of post-ECT relapse. METHOD A 20-week, randomized, double-blind, placebo-controlled trial. Patients aged 18 to 65 years diagnosed with Diagnostic and Statistical Manual of Mental Disorders major depressive disorder, with or without psychotic features, with initial Montgomery-Asberg Depression Rating Scale scores higher than 22, underwent 8 bilateral ECT sessions (2 per week). Randomization to c-pharm early, c-pharm late, and placebo groups in 2:2:1, respectively, was performed at the completion of the fourth ECT session. After randomization, subjects in the c-pharm early group were given sertraline at 150 mg/d. Subjects in the c-pharm late group were first given placebo, which was substituted with sertraline at 150 mg/d at the completion of the eight ECT. Relapse was defined as a Montgomery-Asberg Depression Rating Scale score of 16 or higher. RESULTS Seventy-three percent of the patients responded to the given treatment. The relapse rates were 12.5% in the c-pharm early group, 28% in the c-pharm late group, and 67% in the placebo group (P = 0.09). The c-pharm early strategy resulted in significantly lower relapse rates and longer well time compared with the placebo (P = 0.04). When the trend with the initiation of the c-pharm intervention was investigated in the 3 groups with equally spaced trend weights, the time of initiation was found to have a significant effect on the probability of the remaining well (P = 0.03). CONCLUSIONS Comparative efficacy of c-pharm early and late strategies in providing improved protection against post-ECT relapse of major depressive disorder needs to be further explored.
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Riluzole for relapse prevention following intravenous ketamine in treatment-resistant depression: a pilot randomized, placebo-controlled continuation trial. Int J Neuropsychopharmacol 2010; 13:71-82. [PMID: 19288975 PMCID: PMC3883127 DOI: 10.1017/s1461145709000169] [Citation(s) in RCA: 199] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The N-methyl-D-aspartate (NMDA) glutamate receptor antagonist ketamine may have rapid, albeit transient, antidepressant properties. This study in patients with treatment-resistant major depression (TRD) aimed to (1) replicate the acute efficacy of single-dose intravenous (i.v.) ketamine; (2) test the efficacy of the glutamate-modulating agent riluzole in preventing post-ketamine relapse; and (3) examine whether pretreatment with lamotrigine would attenuate ketamine's psychotomimetic effects and enhance its antidepressant activity. Twenty-six medication-free patients received open-label i.v. ketamine (0.5 mg/kg over 40 min). Two hours prior to infusion, patients were randomized to lamotrigine (300 mg) or placebo. Seventeen patients (65%) met response criterion (50% reduction from baseline on the Montgomery-Asberg Depression Rating Scale) 24 h following ketamine. Lamotrigine failed to attenuate the mild, transient side-effects associated with ketamine and did not enhance its antidepressant effects. Fourteen patients (54%) met response criterion 72 h following ketamine and proceeded to participate in a 32-d, randomized, double-blind, placebo-controlled, flexible-dose continuation trial of riluzole (100-200 mg/d). The main outcome measure was time-to-relapse. An interim analysis found no significant differences in time-to-relapse between riluzole and placebo groups [log-rank chi(2) = 0.17, d.f. = 1, p = 0.68], with 80% of patients relapsing on riluzole vs. 50% on placebo. The trial was thus stopped for futility. This pilot study showed that a sub-anaesthetic dose of i.v. ketamine is well-tolerated in TRD, and may have rapid and sustained antidepressant properties. Riluzole did not prevent relapse in the first month following ketamine. Further investigation of relapse prevention strategies post-ketamine is necessary.
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Kennedy SH, Milev R, Giacobbe P, Ramasubbu R, Lam RW, Parikh SV, Patten SB, Ravindran AV. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. IV. Neurostimulation therapies. J Affect Disord 2009; 117 Suppl 1:S44-53. [PMID: 19656575 DOI: 10.1016/j.jad.2009.06.039] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Accepted: 06/23/2009] [Indexed: 01/28/2023]
Abstract
BACKGROUND In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. There is renewed interest in refined approaches to brain stimulation, particularly for treatment resistant major depressive disorder (MDD). METHODS The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support. This section on "Neurostimulation Therapies" is one of 5 guidelines articles. RESULTS Among the four forms of neurostimulation reviewed in this section, electroconvulsive therapy (ECT) has the most extensive evidence, spanning seven decades. Repetitive transcranial magnetic (rTMS) and vagus nerve stimulation (VNS) have been approved to treat depressed adults in both Canada and the United States with a much smaller evidence base. There is also emerging evidence that deep brain stimulation (DBS) is effective for otherwise treatment resistant depression, but this is an investigational approach in 2009. LIMITATIONS Compared to other modalities for the treatment of MDD, the data based is limited by the relatively small numbers of randomized controlled trials (RCTs) and small sample sizes. CONCLUSIONS There is most evidence to support ECT as a first-line treatment under specific circumstances and rTMS as a second-line treatment. Evidence to support VNS is less robust and DBS remains an investigational treatment.
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Current world literature. Addictive disorder. Curr Opin Psychiatry 2009; 22:331-6. [PMID: 19365188 DOI: 10.1097/yco.0b013e32832ae253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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