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Arnaud A, Benner J, Suthoff E, Werneburg B, Reinhart M, Sussman M, Kessler RC. The impact of early remission on disease trajectory and patient outcomes in major depression disorder (MDD): A targeted literature review and microsimulation modeling approach based on the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. J Affect Disord 2023; 325:264-272. [PMID: 36608852 DOI: 10.1016/j.jad.2022.12.147] [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: 12/21/2021] [Revised: 11/30/2022] [Accepted: 12/23/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND While literature has suggested that the duration of a major depressive episode (MDE) may affect both symptomatic and functional outcomes in major depressive disorder (MDD), study designs are limited in their ability to isolate a causal relationship. METHODS A targeted literature review was conducted using the MEDLINE database to assess whether there was an association between (1) shorter duration of an MDE, or (2) increased rapidity of symptom improvement, and MDD outcomes in adult patients. Given findings from the literature, we hypothesized that rapid symptom improvement could be associated with other longer-term clinical outcomes and used a previously-developed microsimulation model to test this hypothesis. The base case of the model replicated step-therapy treatment patterns, for 10,000 simulated patients, based on lines of therapy related to standard of care, observed remission rates, and observed time to relapse from the STAR*D study. In alternative scenario analyses, the step 1 remission rate was varied by +25 % and +50 % from the base case value to simulate the potential impact of improved earlier remission on disease trajectory and patient-level clinical outcomes. RESULTS The literature review (N = 35 studies) suggests a statistically significant relationship between the duration of MDE or early symptom improvement and MDD outcomes. The microsimulation model corroborated these findings and demonstrated that increasing the rate of remission in step 1 results in patients experiencing decreased number of treatment steps, faster time to remission, decreased rate of reaching treatment-resistant depression, and delayed time to relapse. LIMITATIONS Rates of relapse in STAR*D were deemed unreliable due to the high-loss of follow-up; rates of relapse for the MDD DTM were instead derived using parametric extrapolation methods (i.e., exponential, Weibull, log-logistic, Gaussian, log-normal, logistic). Adherence to treatment was assumed to be 100 %; however, non-adherence is expected to result in lower cumulative remission rates. CONCLUSION Findings from the literature, coupled with quantification through a novel microsimulation model, demonstrate the potential impact of increased remission on disease trajectory and patient outcomes in MDD. While additional analyses with the model may be warranted to explore the impact of novel interventions on population health, including long-term outcomes (i.e., 5-year follow-up, lifetime follow-up), efforts by clinicians to increase remission early in the disease trajectory may improve long-term outcomes.
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The impact of the number of electroconvulsive therapy sessions on relapse in major depressive disorder. Int J Psychiatry Clin Pract 2022; 26:376-380. [PMID: 35152820 DOI: 10.1080/13651501.2022.2035771] [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] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) is an effective treatment of major depressive disorder (MDD). However, high relapse rates after ECT represent clinical problems. To date, influence of number of ECT sessions on relapse rate remains to be elucidated. We evaluated associations between number of ECT sessions and relapse rate. METHODS This retrospective review collected clinical data of 53 patients with MDD who received ECT. They underwent a 1-year follow-up after their last ECT session. We performed survival analysis to evaluate associations between number of ECT sessions and time until rehospitalisation or suicide. RESULTS The patients were divided into a higher number of ECT group (≧8 sessions) and lower number of ECT group (<8 sessions). No significant difference was found regarding the patients' clinical and demographic data. Survival analysis using log-rank test revealed that the cumulative survival rate in the higher number of ECT group (79%) was higher compared with the lower number of ECT group (49%) (p = 0.042). CONCLUSION Patients who underwent a higher number of ECT had improved survival rate compared with those who received a lower number. Therefore, additional sessions might be necessary, even in patients who achieved remission within seven ECT sessions, to prevent relapse.Key pointsHigh rate of relapse after ECT is a key problem.Impact of the Number of ECT sessions on relapse remains to be elucidated.In the present study, the patients with MDD who underwent eight or more sessions of ECT showed significant lower relapse rate compared with those who received less than eight sessions.
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Zheng W, He M, Gu LM, Lao GH, Wang DF, Mai JX, Wu HW, Nie S, Huang X. Early improvement as a predictor of final remission in patients with treatment-resistant depression receiving electroconvulsive therapy with ketofol anesthesia. J Affect Disord 2022; 310:223-227. [PMID: 35550826 DOI: 10.1016/j.jad.2022.05.027] [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: 10/28/2021] [Revised: 03/20/2022] [Accepted: 05/05/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To examine whether early symptom improvement can predict eventual remission following electroconvulsive therapy (ECT) with ketamine plus propofol (ketofol) anesthesia in patients with treatment-resistant depression (TRD). METHODS Thirty Han Chinese subjects suffering from TRD were administered ketofol anesthesia during ECT. Remission was defined as a score of ≤7 on the 17-item Hamilton Depression Rating Scale (HAMD-17). Receiver operating characteristic (ROC) curves were applied to identify the number of ECT sessions (i.e., 1, 2, 3, or 4 ECT sessions) that had the best discriminative capacity for eventual remission. The best definition of early improvement to predict final remission was determined by using the Youden index. RESULTS Of the 30 patients with TRD, 16 (53.3%) and 30 (100%) were classified as remitters and responders, respectively. A 45% reduction in the HAMD-17 score after 3 ECT sessions was the optimum definition of early improvement in the prediction of eventual remission, with relatively good sensitivity (88%) and specificity (93%). Patients with than without early improvement had a greater possibility of achieving favorable ECT outcomes. CONCLUSION Final remission of TRD following ECT with ketofol anesthesia appeared to be predicted by early improvement, as indicated by a 45% reduction in HAMD-17 score after 3 ECT sessions.
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Affiliation(s)
- Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Mei He
- Nanning Fifth People's Hospital, Nanning, China
| | - Li-Mei Gu
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guo-Hui Lao
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Dan-Feng Wang
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jian-Xin Mai
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Hua-Wang Wu
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Sha Nie
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Xiong Huang
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China.
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de Arriba-Arnau A, Soria V, Salvat-Pujol N, Menchón JM, Urretavizcaya M. Similar clinical improvement of depression using 0.5-ms and 1-ms pulse widths in bilateral electroconvulsive therapy. Eur Arch Psychiatry Clin Neurosci 2021; 271:465-473. [PMID: 31832757 DOI: 10.1007/s00406-019-01089-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/23/2019] [Indexed: 01/26/2023]
Abstract
There is a lack of research regarding 0.5-ms pulse width (PW) in bilateral electroconvulsive therapy (ECT). The aim of this study was to compare the efficacy and number of treatment sessions between groups receiving 0.5-ms and 1-ms PW ECT. Ninety-four patients with unipolar major depression treated with acute bilateral ECT were analysed retrospectively, grouped as consecutive patients treated with 0.5-ms PW ECT (n = 47), and age- and sex-matched patients treated with 1-ms PW ECT. Clinical and ECT data were extracted from clinical records. Symptom evaluations and global cognitive screening at baseline and post-ECT were administered by trained psychiatrists. The Hamilton Rating Scale for Depression (HDRS-21) was rated weekly. Efficacy and number of treatment sessions were compared between groups. PW was explored as a predictor of mean decrease in HDRS and number of treatment sessions by regression models. Group characteristics did not differ at baseline. The mean decrease in HDRS in the 0.5- and 1-ms PW [25.85 (7.79) vs. 24.33 (6.99), respectively], response (95.7% vs. 97.9%), remission (87.2% vs. 80.9%) and mean number of treatment sessions [11.28 (3.85) vs. 11.34 (3.36)] were not significantly different. Episode duration and severity, and previous ECT predicted HDRS decrease. Severity at baseline and the 6th session, the dosing method and the last ECT treatment dose predicted the number of treatment sessions needed. PW was not significant in the regressions models. The results suggest that both PWs perform similarly in bilateral ECT for depression, resulting in equivalent antidepressant efficacy and number of treatment sessions needed.
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Affiliation(s)
- Aida de Arriba-Arnau
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL) Neurosciences Group - Psychiatry and Mental Health, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Madrid, Spain
| | - Virginia Soria
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL) Neurosciences Group - Psychiatry and Mental Health, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Madrid, Spain.,Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Neus Salvat-Pujol
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL) Neurosciences Group - Psychiatry and Mental Health, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Madrid, Spain
| | - José M Menchón
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL) Neurosciences Group - Psychiatry and Mental Health, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Madrid, Spain.,Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Mikel Urretavizcaya
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL) Neurosciences Group - Psychiatry and Mental Health, L'Hospitalet de Llobregat, Barcelona, Spain. .,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Madrid, Spain. .,Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain.
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Carstens L, Hartling C, Stippl A, Domke AK, Herrera-Mendelez AL, Aust S, Gärtner M, Bajbouj M, Grimm S. A symptom-based approach in predicting ECT outcome in depressed patients employing MADRS single items. Eur Arch Psychiatry Clin Neurosci 2021; 271:1275-1284. [PMID: 34269881 PMCID: PMC8429160 DOI: 10.1007/s00406-021-01301-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/04/2021] [Indexed: 11/04/2022]
Abstract
Establishing symptom-based predictors of electroconvulsive therapy (ECT) outcome seems promising, however, findings concerning the predictive value of distinct depressive symptoms or subtypes are limited; previous factor-analytic approaches based on the Montgomery-Åsberg Depression Rating Scale (MADRS) remained inconclusive, as proposed factors varied across samples. In this naturalistic study, we refrained from these previous factor-analytic approaches and examined the predictive value of MADRS single items and their change during the course of ECT concerning ECT outcome. We used logistic and linear regression models to analyze MADRS data routinely assessed at three time points in 96 depressed psychiatric inpatients over the course of ECT. Mean age was 53 years (SD 14.79), gender ratio was 58:38 (F:M), baseline MADRS score was M = 30.20 (SD 5.42). MADRS single items were strong predictors of ECT response, remission and overall symptom reduction, especially items 1 (apparent sadness), 2 (reported sadness) and 8 (inability to feel), assessing affective symptoms. Strongest effects were found for regression models including item 2 (reported sadness) with up to 80% correct prediction of ECT outcome. ROC analyses were performed to estimate the optimal cut-point for treatment response. MADRS single items during the course of ECT might pose simple, reliable, time- and cost-effective predictors of ECT outcome. More severe affective symptoms of depression at baseline and a stronger reduction of these affective symptoms during the course of ECT seem to be positively associated with ECT outcome. Precise cut-off values for clinical use were proposed. Generally, these findings underline the benefits of a symptom-based approach in depression research and treatment in addition to depression sum-scores and generalized diagnoses.
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Affiliation(s)
- Luisa Carstens
- Department of Psychiatry, Centre for Affective Neuroscience (CAN), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Campus Benjamin, Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - Corinna Hartling
- grid.484013.aDepartment of Psychiatry, Centre for Affective Neuroscience (CAN), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Campus Benjamin, Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Anna Stippl
- grid.484013.aDepartment of Psychiatry, Centre for Affective Neuroscience (CAN), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Campus Benjamin, Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Ann-Kathrin Domke
- grid.484013.aDepartment of Psychiatry, Centre for Affective Neuroscience (CAN), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Campus Benjamin, Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Ana Lucia Herrera-Mendelez
- grid.484013.aDepartment of Psychiatry, Centre for Affective Neuroscience (CAN), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Campus Benjamin, Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Sabine Aust
- grid.484013.aDepartment of Psychiatry, Centre for Affective Neuroscience (CAN), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Campus Benjamin, Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Matti Gärtner
- grid.484013.aDepartment of Psychiatry, Centre for Affective Neuroscience (CAN), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Campus Benjamin, Franklin, Hindenburgdamm 30, 12203 Berlin, Germany ,grid.466457.20000 0004 1794 7698Department of Psychology, MSB Medical School Berlin, Rüdesheimer Str. 50, 14197 Berlin, Germany
| | - Malek Bajbouj
- grid.484013.aDepartment of Psychiatry, Centre for Affective Neuroscience (CAN), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Campus Benjamin, Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Simone Grimm
- grid.484013.aDepartment of Psychiatry, Centre for Affective Neuroscience (CAN), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Campus Benjamin, Franklin, Hindenburgdamm 30, 12203 Berlin, Germany ,grid.7400.30000 0004 1937 0650Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Lenggstrasse 31, 8032 Zurich, Switzerland ,grid.466457.20000 0004 1794 7698Department of Psychology, MSB Medical School Berlin, Rüdesheimer Str. 50, 14197 Berlin, Germany
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Kraus C, Kadriu B, Lanzenberger R, Zarate CA, Kasper S. Prognosis and Improved Outcomes in Major Depression: A Review. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2020; 18:220-235. [PMID: 33343240 DOI: 10.1176/appi.focus.18205] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
(Reprinted from Transl Psychiatry. 2019 Apr 3; 9(1):127. Open access; is licensed under a Creative Commons Attribution 4.0 International License).
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Hicks PB, Sevilimedu V, Johnson GR, Tal I, Chen P, Davis LL, Vertrees JE, Mohamed S, Zisook S. Predictability of Nonremitting Depression After First 2 Weeks of Antidepressant Treatment: A VAST‐D Trial Report. PSYCHIATRIC RESEARCH AND CLINICAL PRACTICE 2019; 1:58-67. [PMID: 36101874 PMCID: PMC9176018 DOI: 10.1176/appi.prcp.20190003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 05/12/2019] [Accepted: 06/18/2019] [Indexed: 11/30/2022] Open
Abstract
Objective: In this secondary analysis of data from the Veterans Affairs Augmentation and Switching Treatments for Improving Depression Outcomes (VAST‐D) study, the authors sought to determine the effectiveness of early improvement (or lack thereof) for predicting remission from depression with antidepressant therapy. Methods: This study used data from the VAST‐D study, a multisite, randomized, single‐blind trial with parallel assignment to one of three medication interventions for 1,522 veterans whose major depressive disorder was unresponsive to at least one course of antidepressant treatment meeting minimal standards for dosage and duration. The authors calculated the positive predictive value (PPV) and negative predictive value (NPV) of early improvement on remission, response, or greater than minimal improvement from depression for various degrees of improvement (10%–50%) on the Quick Inventory of Depressive Symptomatology–Clinician Rated (QIDS‐C) at 1, 2, 4, and 6 weeks. Results: The end of week 2 of treatment was identified as the best time to evaluate early improvement. The presence of a ≥20% drop from the baseline QIDS‐C score by the end of week 2 resulted in a PPV for remission of 38% and an NPV of 93% by week 12. Extending the observational window to week 6 minimally improved NPV (97%). This association did not differ across treatment groups. Conclusions: A lack of early improvement at the end of week 2 of antidepressant therapy can be used to inform clinical decisions on the likelihood of nonremission of depression during the subsequent 10 weeks, even when dosage optimization is incomplete.
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Affiliation(s)
- Paul B. Hicks
- Department of PsychiatryBaylor Scott & White Health
- Texas A&M College of MedicineTempleTexas
| | - Varadan Sevilimedu
- Yale University School of Public HealthNew HavenConnecticut
- Cooperative Studies Program Coordinating CenterVeterans Affairs (VA) Connecticut Healthcare SystemWest Haven
| | - Gary R. Johnson
- Cooperative Studies Program Coordinating CenterVeterans Affairs (VA) Connecticut Healthcare SystemWest Haven
| | | | - Peijun Chen
- Louis Stokes Cleveland VA Medical CenterClevelend
| | - Lori L. Davis
- Tuscaloosa VA Medical CenterTuscaloosaAlabama
- University of Alabama School of MedicineBirmingham
| | - Julia E. Vertrees
- Cooperative Studies Program Clinical Research Pharmacy Coordinating CenterAlbuquerqueNew Mexico
| | - Somaia Mohamed
- VA New England Mental Illness Research, Education, and Clinical CenterVA Connecticut Healthcare SystemWest Haven
| | - Sidney Zisook
- VA San Diego Healthcare SystemSan Diego
- Department of PsychiatryUniversity of CaliforniaSan Diego
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Birkenhager TK, Roos J, Kamperman AM. Improvement after two sessions of electroconvulsive therapy predicts final remission in in-patients with major depression. Acta Psychiatr Scand 2019; 140:189-195. [PMID: 31104321 PMCID: PMC6771780 DOI: 10.1111/acps.13054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To investigate whether early improvement, measured after two electroconvulsive therapy (ECT) sessions, is a good predictor of eventual remission in severely depressed in-patients receiving ECT. METHOD A prospective cohort study was performed that included 89 major depressive disorder in-patients treated with bilateral ECT. Sensitivity, specificity, and predictive values were computed for various definitions of early improvement (15%, 20%, 25%, and 30% reduction on the Montgomery Asberg depression rating scale (MADRS) score) after 1 week (i.e. two sessions) of ECT regarding prediction of remission (final MADRS score ≤ 9). RESULTS A 15% reduction in MADRS score appeared to be the best definition of early improvement, with modest sensitivity (51%) and relatively good specificity (79%). Kaplan-Meier analysis showed a more than 2-week shorter time to remission in patients with early improvement compared with patients lacking early improvement. CONCLUSION Early improvement during an ECT course may be assessed after two ECT sessions. Such improvement, defined as a 15% reduction in the MADRS score, is a moderately sensitive predictor for eventual remission in an in-patient population with severe major depression.
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Affiliation(s)
- T. K. Birkenhager
- Department of PsychiatryErasmus Medical CentreRotterdamThe Netherlands
| | - J. Roos
- Department of PsychiatryErasmus Medical CentreRotterdamThe Netherlands
| | - A. M. Kamperman
- Department of PsychiatryErasmus Medical CentreRotterdamThe Netherlands
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Kraus C, Kadriu B, Lanzenberger R, Zarate Jr. CA, Kasper S. Prognosis and improved outcomes in major depression: a review. Transl Psychiatry 2019; 9:127. [PMID: 30944309 PMCID: PMC6447556 DOI: 10.1038/s41398-019-0460-3] [Citation(s) in RCA: 202] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/10/2019] [Accepted: 02/11/2019] [Indexed: 02/07/2023] Open
Abstract
Treatment outcomes for major depressive disorder (MDD) need to be improved. Presently, no clinically relevant tools have been established for stratifying subgroups or predicting outcomes. This literature review sought to investigate factors closely linked to outcome and summarize existing and novel strategies for improvement. The results show that early recognition and treatment are crucial, as duration of untreated depression correlates with worse outcomes. Early improvement is associated with response and remission, while comorbidities prolong course of illness. Potential biomarkers have been explored, including hippocampal volumes, neuronal activity of the anterior cingulate cortex, and levels of brain-derived neurotrophic factor (BDNF) and central and peripheral inflammatory markers (e.g., translocator protein (TSPO), interleukin-6 (IL-6), C-reactive protein (CRP), tumor necrosis factor alpha (TNFα)). However, their integration into routine clinical care has not yet been fully elucidated, and more research is needed in this regard. Genetic findings suggest that testing for CYP450 isoenzyme activity may improve treatment outcomes. Strategies such as managing risk factors, improving clinical trial methodology, and designing structured step-by-step treatments are also beneficial. Finally, drawing on existing guidelines, we outline a sequential treatment optimization paradigm for selecting first-, second-, and third-line treatments for acute and chronically ill patients. Well-established treatments such as electroconvulsive therapy (ECT) are clinically relevant for treatment-resistant populations, and novel transcranial stimulation methods such as theta-burst stimulation (TBS) and magnetic seizure therapy (MST) have shown promising results. Novel rapid-acting antidepressants, such as ketamine, may also constitute a paradigm shift in treatment optimization for MDD.
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Affiliation(s)
- Christoph Kraus
- 0000 0000 9259 8492grid.22937.3dDepartment of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria ,0000 0001 2297 5165grid.94365.3dSection on Neurobiology and Treatment of Mood Disorders, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA
| | - Bashkim Kadriu
- 0000 0001 2297 5165grid.94365.3dSection on Neurobiology and Treatment of Mood Disorders, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA
| | - Rupert Lanzenberger
- 0000 0000 9259 8492grid.22937.3dDepartment of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Carlos A. Zarate Jr.
- 0000 0001 2297 5165grid.94365.3dSection on Neurobiology and Treatment of Mood Disorders, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA
| | - Siegfried Kasper
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria.
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