Influence of age on ECT efficacy in depression and the mediating role of psychomotor retardation and psychotic features

A prediction model for electroconvulsive therapy effectiveness in patients with major depressive disorder from the Dutch ECT Consortium (DEC)

Reliable predictors for electroconvulsive therapy (ECT) effectiveness would allow a more precise and personalized approach for the treatment of major depressive disorder (MDD). Prediction models were created using a priori selected clinical variables based on previous meta-analyses. Multivariable linear regression analysis was used, applying backwards selection to determine predictor variables while allowing non-linear relations, to develop a prediction model for depression outcome post-ECT (and logistic regression for remission and response as secondary outcome measures). Internal validation and internal-external cross-validation were used to examine overfitting and generalizability of the model's predictive performance. In total, 1892 adult patients with MDD were included from 22 clinical and research cohorts of the twelve sites within the Dutch ECT Consortium. The final primary prediction model showed several factors that significantly predicted a lower depression score post-ECT: higher age, shorter duration of the current depressive episode, severe MDD with psychotic features, lower level of previous antidepressant resistance in the current episode, higher pre-ECT global cognitive functioning, absence of a comorbid personality disorder, and a lower level of failed psychotherapy in the current episode. The optimism-adjusted R² of the final model was 19%. This prediction model based on readily available clinical information can reduce uncertainty of ECT outcomes and hereby inform clinical decision-making, as prompt referral for ECT may be particularly beneficial for individuals with the above-mentioned characteristics. However, despite including a large number of pretreatment factors, a large proportion of the variance in depression outcome post-ECT remained unpredictable.

Why is electroconvulsive therapy for depression more effective in older age? A causal mediation analysis

BACKGROUND

Older people with depression exhibit better response to electroconvulsive therapy (ECT). We aimed to measure the total effect of age on ECT response and investigate whether this effect is mediated by psychotic features, psychomotor retardation, psychomotor agitation, age of onset, and episode duration.

METHODS

We pooled data from four prospective Irish studies where ECT was administered for a major depressive episode (unipolar or bipolar) with baseline score ≥21 on the 24-item Hamilton Depression Rating Scale (HAM-D). The primary outcome was change in HAM-D between baseline and end of treatment. The estimands were total effect of age, estimated using linear regression, and the indirect effects for each putative mediator, estimated using causal mediation analyses.

RESULTS

A total of 256 patients (mean age 57.8 [SD = 14.6], 60.2% female) were included. For every additional 10 years of age, HAM-D was estimated to decrease by a further 1.74 points over the ECT period (p < 0.001). Age acted on all putative mediators. Mechanistic theories, whereby a mediator drives treatment response, were confirmed for all putative mediators except age of onset. Consequently, mediation of the effect of age on change in HAM-D could be demonstrated for psychotic features, psychomotor retardation, psychomotor agitation, and episode duration but not for age of onset.

CONCLUSIONS

A total of 43.1% of the effect of older age on increased ECT response was explained by the mediators. Treatment planning could be improved by preferentially offering ECT to older adults, especially if presenting with psychotic features, greater severity of psychomotor disturbance, and earlier in the episode.

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.

Prediction of electroconvulsive therapy response and remission in late-life depression: a review

Electroconvulsive therapy is an effective and well-tolerated antidepressant treatment for the elderly population. The place of electroconvulsive therapy in the treatment sequence for depression in the elderly is currently not well established. This review aims to identify the factors that contribute to a positive response and remission in elderly patients with depression undergoing electroconvulsive therapy treatment. We searched five bibliographic databases (Medline ALL Ovid, Embase.com, APA PsycInfo Ovid, Cochrane Library Wiley and Web of Science Core Collection) for articles published between 1995 and June 2023. Of the 2149 articles screened, 19 were included in the review. No significant associations were found between remission and/or response and salivary cortisol, baseline hippocampal and white matter hyperintensities, total amyloid load or global cortical atrophy. The reviewed articles did not show a significant difference in remission between unilateral and bilateral electroconvulsive therapy treatment. Other interesting findings are that moderately elevated levels of CRP and S100B levels, lower retardation scores, poorer performance on the word reading task at baseline and longer post-ictal reorientation time may be associated with higher remission and/or response rates. Medial temporal atrophy can be associated with lower Montgomery-Åsberg Depression Rating Scale (MADRS) decrease after electroconvulsive therapy. Finally, elderly patients had higher rates of electroconvulsive therapy response; retardation and psychotic features may mediate this association. Incorporation of this data into clinical practice may facilitate a personalised approach to electroconvulsive therapy. However, research on this topic is scarce and there are few studies that focus specifically on older people.

The influence of age on ECT efficacy in depression, mania, psychotic depression and schizophrenia: A transdiagnostic analysis

AIM

ECT use is variable across age groups. We aim to investigate the effect of age on ECT response among patients with depression, psychotic depression, mania and schizophrenia.

METHODS

Our retrospective observational study included patients from the Institute of Mental Health (Singapore) who were initiated on ECT (March 2017-February 2023). MADRS and BPRS scores were assessed 1-2 days before the first ECT and after the 6th session. The association between age group and ECT response was analyzed by ANOVA and generalized linear regression. A one-way sensitivity analysis was performed with age as a continuous variable.

RESULTS

166 (15.7%) patients were "young-age (≤26 years)", 634 (60%) patients were in the "middle-age (27-59 years)" group and 256 (24.3%) were "old-age (≥60 years)". The association between older age and post-ECT improvement in patients with depression was significant in the categorical age analysis but it did not persist in the sensitivity analysis. No significant association between age and ECT response was noted in patients with bipolar disorder and schizophrenia as evidenced by both categorical and continuous age analyses. In a small subgroup with psychotic depression, younger patients improved significantly more than older patients post-ECT.

CONCLUSION

Patients with unipolar or bipolar depression, mania, or schizophrenia, regardless of age, respond favourably to ECT. Other associated factors such as psychomotor and psychotic symptoms, disease severity and number of failed pharmacotherapies should be considered in predicting ECT response. Younger patients with psychotic depression may respond better to ECT.

Clinical Outcomes of Electroconvulsive Therapy (ECT) for Depression in Older Old People Relative to Other Age Groups Across the Adult Life Span: A CARE Network Study

INTERVENTION

Electroconvulsive therapy (ECT) is a commonly used treatment for severe psychiatric illness in older adults, including in the 'older old' population aged 80 years and above. However, there can sometimes be a reluctance to treat the 80+ year old age group with ECT due to medical comorbidities, frailty, and concerns about cognition.

OBJECTIVE, DESIGN, SETTING, AND PARTICIPANTS

This multi-site, longitudinal Australian study aimed to investigate the effectiveness and safety of ECT in older old people compared with younger age groups. Data from 310 people receiving ECT for depression at three participating hospitals was collected in a naturalistic setting, between 2015 and 2022.

MEASUREMENTS

Clinical ratings were conducted pre-ECT and end-acute ECT using the Montgomery-Åsberg Depression Rating Scale (MADRS). Cognitive outcomes were assessed using the Montreal Cognitive Assessment (MoCA).

RESULTS

Older old adults demonstrated a significant reduction MADRS scores at post-treatment. They were more likely to meet remission criteria compared with the younger age groups. Older old adults were also less likely to show clinically significant cognitive decline post-ECT, and were more likely to show clinically significant cognitive improvement post-ECT compared with younger age groups.

CONCLUSIONS

ECT is highly effective in treating severe psychiatric illness in older old adults. Relative to the younger age groups, the older old group were more likely to remit with ECT and a greater proportion showed cognitive improvement post-ECT. These findings suggest that ECT should be considered as a valuable and safe treatment option for older old individuals with depression.

Electroconvulsive therapy for adolescents with severe depressive episode and suicidality: retrospective comparison between responders and non-responders

BACKGROUND

For adolescents with major depression who exhibit suicidal tendencies, Electroconvulsive Therapy (ECT) is increasingly adopted in clinical practice. Yet, the precise mechanisms behind its effectiveness remain elusive, and studies on factors that influence treatment outcomes are scarce.

METHODS

In this retrospective comparative study, we included all adolescent severe depressive episode patients with suicidal tendencies admitted to the Psychiatry Department of the First Affiliated Hospital of Chongqing Medical University between 2017 and 2021 and received ECT treatment. By collecting data on personal history, medical history, and standard treatment features, we established demographic, disease, medication, and ECT treatment factors variables. Patients were divided into effective and ineffective groups based on the Clinical Global Impressions-Improvement (CGI-I) scale scores, and differences between outcomes were compared. Logistic regression analyses were used to identify factors independently associated with ineffectiveness.

RESULTS

A total of 494 adolescent severe depressive episode patients with suicidal behavior who received ECT were included in this study. According to CGI-I scores, the treatment was effective in 361 patients (73.1%) and ineffective in 133 patients (26.9%). Logistic regression analyses showed that 8 to 12 and 12 to 16 ECT sessions reduced the risk of ineffectiveness compared to fewer than 4 sessions. The risk of ineffectiveness decreased with age and increased with comorbidity with obsessive-compulsive disorder (OCD). Compared to sertraline, escitalopram was associated with a heightened risk of futility, whereas olanzapine and aripiprazole demonstrated a reduced risk when contrasted with quetiapine.

CONCLUSIONS

ECT's ineffectiveness in treating adolescent severe depressive episode with suicidal behavior decreases with age, and comorbidity with OCD significantly increases the risk of treatment failure. Fewer than 8 ECT sessions may hinder achieving satisfactory results.

Unmasking patient diversity: Exploring cognitive and antidepressive effects of electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is an established treatment for depression, but more data on effectiveness and safety in clinical practice is needed. The aim of this register-based study was to investigate short-term effectiveness and cognitive safety after ECT, evaluated by clinicians and patients. Secondary, we investigated predictors for remission and cognitive decline.

METHODS

The study included 392 patients from the Regional Register for Neurostimulation Treatment in Western Norway. Depressive symptoms and cognitive function were assessed with Montgomery-Åsberg Depression Rating Scale and Mini-Mental State Examination (clinician-rated) and Beck Depression Inventory and Everyday Memory Questionnaire (patient-rated). Assessments were done prior to ECT-series and a mean of 1.7 days after (range 6 days before and 12 days after) end of ECT-series. Paired samples t-tests were extended by detailed, clinically relevant subgroups. Predictors were examined using logistic regression.

RESULTS

Clinician- and patient-rated remission rates were 49.5 and 41.0%, respectively. There was a large reduction in depressive symptoms and a small improvement in cognition after ECT, but we also identified subgroups with non-response of ECT in combination with cognitive decline (4.6% clinician-rated, 15.7% patient-rated). Positive predictors for patient- and clinician-rated remission were increasing age, shorter duration of depressive episode, and psychotic features. Antipsychotic medication at the commencement of treatment and previous ECT-treatment gave higher odds of clinician-rated remission, whereas higher pretreatment subjective depression level was associated with lower odds for patient-rated remission. Clinician-rated cognitive decline was predicted by higher pretreatment MMSE scores, whereas psychotic features, increasing age, and greater pretreatment subjective memory concerns were associated with lower odds for patient-rated cognitive decline.

CONCLUSIONS

Our study supports ECT as an effective and safe treatment, although subgroups have a less favorable outcome. ECT should be considered at an early stage for older patients suffering from depression with psychotic features. Providing comprehensive and balanced information from clinicians and patients perspectives on effects and side effects, may assist in a joint consent process.

Dynamics of Depressive and Psychomotor Symptoms During Electroconvulsive Therapy in Older Depressive Patients: A Case Series

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.

Spontaneous beta power, motor-related beta power and cortical thickness in major depressive disorder with psychomotor disturbance

INTRODUCTION

The psychomotor disturbance is a common symptom in patients with major depressive disorder (MDD). The neurological mechanisms of psychomotor disturbance are intricate, involving alterations in the structure and function of motor-related regions. However, the relationship among changes in the spontaneous activity, motor-related activity, local cortical thickness, and psychomotor function remains unclear.

METHOD

A total of 140 patients with MDD and 68 healthy controls performed a simple right-hand visuomotor task during magnetoencephalography (MEG) scanning. All patients were divided into two groups according to the presence of psychomotor slowing. Spontaneous beta power, movement-related beta desynchronization (MRBD), absolute beta power during movement and cortical characteristics in the bilateral primary motor cortex were compared using general linear models with the group as a fixed effect and age as a covariate. Finally, the moderated mediation model was tested to examine the relationship between brain metrics with group differences and psychomotor performance.

RESULTS

The patients with psychomotor slowing showed higher spontaneous beta power, movement-related beta desynchronization and absolute beta power during movement than patients without psychomotor slowing. Compared with the other two groups, significant decreases were found in cortical thickness of the left primary motor cortex in patients with psychomotor slowing. Our moderated mediation model showed that the increased spontaneous beta power indirectly affected impaired psychomotor performance by abnormal MRBD, and the indirect effects were moderated by cortical thickness.

CONCLUSION

These results suggest that patients with MDD have aberrant cortical beta activity at rest and during movement, combined with abnormal cortical thickness, contributing to the psychomotor disturbance observed in this patient population.

Influence of Chronic Electroconvulsive Seizures on Plasticity-Associated Gene Expression and Perineuronal Nets Within the Hippocampi of Young Adult and Middle-Aged Sprague-Dawley Rats

BACKGROUND

Electroconvulsive seizure therapy is often used in both treatment-resistant and geriatric depression. However, preclinical studies identifying targets of chronic electroconvulsive seizure (ECS) are predominantly focused on animal models in young adulthood. Given that putative transcriptional, neurogenic, and neuroplastic mechanisms implicated in the behavioral effects of chronic ECS themselves exhibit age-dependent modulation, it remains unknown whether the molecular and cellular targets of chronic ECS vary with age.

METHODS

We subjected young adult (2-3 months) and middle-aged (12-13 months), male Sprague Dawley rats to sham or chronic ECS and assessed for despair-like behavior, hippocampal gene expression, hippocampal neurogenesis, and neuroplastic changes in the extracellular matrix, reelin, and perineuronal net numbers.

RESULTS

Chronic ECS reduced despair-like behavior at both ages, accompanied by overlapping and unique changes in activity-dependent and trophic factor gene expression. Although chronic ECS had a similar impact on quiescent neural progenitor numbers at both ages, the eventual increase in hippocampal progenitor proliferation was substantially higher in young adulthood. We noted a decline in reelin⁺ cell numbers following chronic ECS only in young adulthood. In contrast, an age-invariant, robust dissolution of perineuronal net numbers that encapsulate parvalbumin⁺ neurons in the hippocampus were observed following chronic ECS.

CONCLUSION

Our findings indicate that age is a key variable in determining the nature of chronic ECS-evoked molecular and cellular changes in the hippocampus. This raises the intriguing possibility that chronic ECS may recruit distinct, as well as overlapping, mechanisms to drive antidepressant-like behavioral changes in an age-dependent manner.

A Case Study of Depression in High Achieving Students Associated With Moral Incongruence, Spiritual Distress, and Feelings of Guilt

Psychosocial and cultural factors play an important, but often neglected, role in depression in young individuals. In this article, we present two cases of young, educated males with major depressive disorder and prominent themes of guilt and spiritual distress. We explore the relationship between moral incongruence, spiritual distress, and feelings of guilt with major depressive episodes by presenting two cases of depression in young individuals who were high-achieving students. Both cases presented with low mood, psychomotor slowing, and selective mutism. Upon detailed history, spiritual distress and feelings of guilt due to internet pornographic use (IPU) and the resulting self-perceived addiction and moral incongruence were linked to the initiation and progression of major depressive episodes. The severity of the depressive episode was measured using the Hamilton Depression Scale (HAM-D). Themes of guilt and shame were measured using the State of Guilt and Shame Scale (SSGS). High expectations from the family were also a source of stress. Hence, it is important to keep these factors in mind while managing mental health problems in young individuals. Late adolescence and early adulthood are periods of high stress and vulnerabe to mental illness. Psychosocial determinants of depression in this age group generally go unexplored and unaddressed leading to suboptimal treatment, particularly in developing countries. Further research is needed to assess the importance of these factors and to determine ways to mitigate them.

The impact of the number of electroconvulsive therapy sessions on relapse in major depressive disorder

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.

The utility of the Sydney Melancholia Prototype Index (SMPI) for predicting response to electroconvulsive therapy in depression: A CARE Network study

An enhanced understanding of clinical predictors of positive ECT outcome could assist with the decision to prescribe ECT for select patients. Reliable predictors of ECT response such as psychotic symptoms and age have been identified, however, studies of melancholia and ECT response have been inconsistent. The Sydney Melancholia Prototype Index (SMPI) is a clinical measure designed to differentiate melancholic and non-melancholic depression. This study aimed to investigate whether melancholic depression (as measured by the clinician rated version of the SMPI) predicted a better response to ECT than non-melancholic depression. The study included data collated from four participating sites in the Clinical Alliance for ECT and Related treatments (CARE) network. The primary outcome was response (>50% improvement) on the Montgomery Asberg Depression Rating Scale (MADRS) and the secondary outcome was raw change in MADRS score. Of the 329 depressed patients included in the study, 81% had melancholic features and 76% met criteria for clinical response. SMPI defined melancholia was associated with older age, higher pre-treatment mood scores and presence of psychosis. Melancholia as defined by the SMPI, however, did not significantly predict either clinical response or overall mood improvement with ECT in multivariate analyses. Instead, older age, greater pre-treatment depression severity and the use of bifrontal compared to right unilateral ultrabrief ECT were significant predictors of mood improvement. Path analysis showed that higher pre-treatment mood score and older age were independently associated with mood improvement with ECT.

The Use of ECT in the Elderly-Looking Beyond Depression

PURPOSE OF REVIEW

We reviewed recent evidence on the use of electroconvulsive therapy (ECT) in the geriatric population. This review looked at the literature on depression, for which there is a breadth of data, as well as other conditions that have historically not been as well studied, as well as attempting to provide practical recommendations for ECT practitioners. This review also examined the impact of the COVID-19 pandemic on ECT in the elderly.

RECENT FINDINGS

ECT shows robust efficacy across many psychiatric diseases, from depression and bipolar disorder to psychosis and catatonia. It has also shown positive results at improving behavioral symptoms of dementia, as well as improving motor symptoms seen in Parkinson's disease. It is routinely found to be a safe treatment as well, generally with only minimal transient side effects. ECT should not be considered a "last-resort" treatment for geriatric patients suffering from psychiatric disorders. It has historical and recent literature supporting its use in many psychiatric disorders and has been shown to be safe with minimal side effects when appropriate considerations are taken for the elderly population.

First Acute-Course Electroconvulsive Therapy for Moderate-to-Severe Depression Benefits Patients With or Without Accompanying Baseline Cognitive Impairment

BACKGROUND

Researchers are increasingly investigating therapeutic response associated with new patient subgroups as a way to improve electroconvulsive therapy (ECT) treatment outcomes and reduce adverse events. This study is the first to examine baseline cognitive impairment status as a predictor of clinical outcome in first acute-course ECT patients.

METHODS

Baseline cognitive function at various thresholds and serial depressive symptom severity data from first-time ECT patients were examined using generalized linear mixed-effects models.

RESULTS

Of 1345 patients who met the inclusion criteria, 617 had available data at their third assessment visit (~15th treatment visit). There was a robust improvement in depression symptoms over time (P < 0.0001), and cognitive function was not associated with baseline levels of depressive symptoms or serially measured change in self-reported symptom severity during acute-phase ECT.

CONCLUSIONS

These results indicate that an acute course of ECT for the treatment of moderate-to-severe depression benefits patients with or without accompanying baseline cognitive impairment. These findings may be useful in informing shared decision-making discussions about ECT risks and expected benefits.

Actigraphically measured psychomotor slowing in depression: systematic review and meta-analysis

Psychomotor slowing is a key feature of depressive disorders. Despite its great clinical importance, the pathophysiology and prevalence across different diagnoses and mood states are still poorly understood. Actigraphy allows unbiased, objective, and naturalistic assessment of physical activity as a marker of psychomotor slowing. Yet, the true effect-sizes remain unclear as recent, large systematic reviews are missing. We conducted a novel meta-analysis on actigraphically measured slowing in depression with strict inclusion and exclusion criteria for diagnosis ascertainment and sample duplications. Medline/PubMed and Web-of-Science were searched with terms combining mood-keywords and actigraphy-keywords until September 2021. Original research measuring actigraphy for ⩾24 h in at least two groups of depressed, remitted, or healthy participants and applying operationalized diagnosis was included. Studies in somatically ill patients, N < 10 participants/group, and studies using consumer-devices were excluded. Activity-levels between groups were compared using random-effects models with standardized-mean-differences and several moderators were examined. In total, 34 studies (n = 1804 patients) were included. Patients had lower activity than controls [standardized mean difference (s.m.d.) = -0.78, 95% confidence interval (CI) -0.99 to -0.57]. Compared to controls, patients with unipolar and bipolar disorder had lower activity than controls whether in depressed (unipolar: s.m.d. = -0.82, 95% CI -1.07 to -0.56; bipolar: s.m.d. = -0.94, 95% CI -1.41 to -0.46), or remitted/euthymic mood (unipolar: s.m.d. = -0.28, 95% CI -0.56 to 0.0; bipolar: s.m.d. = -0.92, 95% CI -1.36 to -0.47). None of the examined moderators had any significant effect. To date, this is the largest meta-analysis on actigraphically measured slowing in mood disorders. They are associated with lower activity, even in the remitted/euthymic mood-state. Studying objective motor behavior via actigraphy holds promise for informing screening and staging of affective disorders.

'Rapid speed of response to ECT in bipolar depression: A chart review

OBJECTIVE

To validate a faster speed of response to electroconvulsive therapy (ECT) for bipolar depression (BPD) compared to major depressive disorder (MDD) METHOD: Retrospective chart review on an ECT cohort in an academic hospital setting. Speed of response was defined by the number of ECT treatments needed for response or remission.

RESULTS

Sixty-four depressed patients were included, of whom 53 (MDD: 40, BPD: 13) could be analyzed. The bipolar group responded faster with a mean difference of 3.3 fewer ECT treatments to meet response criteria (MDD 10.4 vs. BPD 7.1, p = 0.054). When using mixed effects regression models for the response/remitter group (n = 35), a faster response for the bipolar group (AIC 252.83 vs 258.55, χ² = 11.72, p = 0.008) was shown. Other factors, such as psychotic features or comorbidity, did not influence the speed of response.

CONCLUSION

This chart review of an ECT cohort in an naturalistic academic hospital setting shows an evident and clinically relevant faster speed of response in bipolar depression.

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.

Distinct predictors of short- versus long-term depression outcomes following electroconvulsive therapy

Patients and clinicians considering electroconvulsive therapy (ECT) for treatment-resistant depression are faced with limited information about the likely long-term outcomes, and the individual characteristics that predict those outcomes. We aimed to identify sociodemographic and clinical predictors of acute ECT response and subsequent long-term depression severity. This prospective longitudinal study followed adult patients at a single academic ECT center. Among 114 participants, 105 completed an index ECT series and 70 were classified as acute ECT responders. Over a 2-year follow-up period, 82 subjects provided data on depression severity (Patient Health Questionnaire; PHQ-9). Better acute ECT response was predicted by less medication resistance, shorter index episode, and psychotic features (p < 0.05). PHQ-9 scores during the two-year follow-up period improved from baseline at all time points (p < 0.000001) but individual scores varied widely. Lower long-term PHQ-9 scores were predicted by better acute therapeutic response to ECT (p = 0.004) but not by ECT adverse effects (p > 0.05). Married status and greater baseline clinician-rated severity were not associated with acute ECT response but those variables did predict lower PHQ-9 scores longitudinally (p < 0.001), independent of other baseline features, initial ECT response, or intensity of ongoing treatment. These findings confirm previously identified predictors of short-term ECT response and demonstrate that distinct individual characteristics predict long-term depression outcomes. An individual's social context appears to strongly influence long-term but not short-term outcomes, suggesting a potential target for post-ECT therapeutic interventions.

Electroconvulsive therapy and psychiatric readmission in major depressive disorder - A population-based register study

OBJECTIVE

The primary aim was to determine whether electroconvulsive therapy (ECT) is associated with reduced risk of psychiatric readmission in major depressive disorder (MDD).

METHODS

This study was based on data from multiple Swedish population-based registries. All adult patients admitted to any Swedish hospital for moderate-to-severe MDD between 2012 and 2018 were included. Participants were divided into two groups depending on whether they received ECT during inpatient care. Follow-up was set at 30 and 90 days from discharge. Data were analyzed using logistic regression, and matching was conducted.

RESULTS

A total of 27,851 unique patients contributed to 41,916 admissions. ECT was used in 26.8% of admissions. In the main multivariate analysis, the risk of both 30- and 90-day readmission was lower in the ECT group than in the non-ECT group. In a matched sensitivity model, the results pointed in the same direction for readmission risk within 30 days, but statistical significance was not reached. ECT-treated subgroups with superior outcomes on readmission risk compared with non-ECT treatment were older, unemployed, married, or widowed patients, those treated with antipsychotics or benzodiazepines before admission, with psychotic features, prior psychiatric hospitalizations, or family history of suicide. However, in patients below 35 years of age, ECT was associated with increased readmission risk.

CONCLUSION

This study suggests that ECT reduces the risk of psychiatric readmission in certain subgroups of patients with MDD. Since patients receiving ECT tend to be more difficult to treat, there is a risk of residual confounding.

Response rate and subjective memory after electroconvulsive therapy in depressive disorders with psychiatric comorbidity

BACKGROUND

Response rates after and tolerability of electroconvulsive therapy (ECT) in depressive disorders with psychiatric comorbidity are uncertain.

METHODS

Data on patients with a depressive episode and a first course of ECT were collected from the Swedish National Quality Register for ECT. Logistic regression analyses, adjusted for gender, age, and depressive episode severity, were used to compare patients with and without comorbidity. The clinical response assessment Clinical Global Impression - Improvement Scale was used in 4413 patients and the memory item from the Comprehensive Psychiatric Rating Scale was used for subjective memory impairment rating after ECT in 3497 patients.

RESULTS

In patients with depressive disorder and comorbid personality disorder or anxiety disorder, 62.7% and 73.5%, respectively, responded after ECT compared with 84.9% in patients without comorbidity [adjusted odds ratio (aOR) 0.43, 95% confidence interval (CI) 0.34-0.55, and aOR 0.61, 95% CI 0.51-0.73, respectively]. The proportion of responding patients with comorbid alcohol use disorder was 77.1%, which was not significantly different from that in patients without comorbidity (aOR 0.75, 95% CI 0.57-1.01). The impact of comorbidity decreased with higher age and depressive episode severity. Subjective ratings of memory impairment did not differ between patients with and without comorbidity.

LIMITATIONS

Observational non-validated clinical data.

CONCLUSIONS

The response rate after ECT in depression may be lower with concurrent personality disorder and anxiety disorder; however, the majority still respond to ECT. This implies that psychiatric comorbidity should not exclude patients from ECT.

Electroconvulsive Therapy and Age: Effectiveness, Safety and Tolerability in the Treatment of Major Depression among Patients under and over 65 Years of Age

Electroconvulsive therapy (ECT) remains the most effective therapy in treatment-resistant depression. However, the safety of ECT has been consistently questioned, particularly among elderly patients. We assessed the efficacy and safety of ECT in patients before and after 65 years old. The study was conducted between 2015 and 2018 and included 91 patients (61 under and 29 over 65 years old) with major depression undergoing ECT. The Hamilton Depression Rating Scale was used to evaluate efficacy. Cognitive functions were assessed using: MMSE, RAVLT, Trail Making Test, Stroop Test and Autobiographical Memory Interview-Short Form. ECT was more effective in older patients as compared to younger (p < 0.001). No serious adverse events were observed in either group. Increased blood pressure and arrhythmias were more common in the older compared to the younger group (p = 0.044 and p = 0.047, respectively), while disturbances of consciousness did not differ between groups (p = 0.820). Most of the cognitive functions remained unchanged compared to baseline, whereas the outcomes of MMSE, RAVLT and Stroop tests showed greater improvements in the older compared to the younger group (all p < 0.05). The decline in the retrieval consistency of autobiographical memory was more pronounced in the younger group (p = 0.024). ECT is a highly effective, safe and well-tolerated method of treating depression regardless of age.

A longitudinal study of the association between basal ganglia volumes and psychomotor symptoms in subjects with late life depression undergoing ECT

Psychomotor dysfunction (PMD) is a core element and key contributor to disability in late life depression (LLD), which responds well to electroconvulsive therapy (ECT). The neurobiology of PMD and its response to ECT are not well understood. We hypothesized that PMD in LLD is associated with lower striatal volume, and that striatal volume increase following ECT explains PMD improvement. We analyzed data from a two-center prospective cohort study of 110 LLD subjects (>55 years) receiving ECT. Brain MRI and assessment of mood, cognition, and PMD was performed 1 week before, 1 week after, and 6 months after ECT. Volumetry of the caudate nucleus, putamen, globus pallidus, and nucleus accumbens was derived from automatically segmented brain MRIs using Freesurfer®. Linear multiple regression analyses were used to study associations between basal ganglia volume and PMD. Brain MRI was available for 66 patients 1 week post ECT and in 22 patients also six months post ECT. Baseline PMD was associated with a smaller left caudate nucleus. One week after ECT, PMD improved and volume increases were detected bilaterally in the caudate nucleus and putamen, and in the right nucleus accumbens. Improved PMD after ECT did not relate to the significant volume increases in these structures, but was predicted by a nonsignificant volume change in the right globus pallidus. No volume differences were detected 6 months after ECT, compared to baseline. Although PMD is related to lower striatal volume in LLD, ECT-induced increase of striatal volume does not explain PMD improvement.

Association between psychomotor disturbance and treatment outcome in psychotic depression: a STOP-PD II report

BACKGROUND

Little is known about the relationship between psychomotor disturbance (PMD) and treatment outcome of psychotic depression. This study examined the association between PMD and subsequent remission and relapse of treated psychotic depression.

METHODS

Two hundred and sixty-nine men and women aged 18-85 years with an episode of psychotic depression were treated with open-label sertraline plus olanzapine for up to 12 weeks. Participants who remained in remission or near-remission following an 8-week stabilization phase were eligible to participate in a 36-week randomized controlled trial (RCT) that compared the efficacy and tolerability of sertraline plus olanzapine (n = 64) with sertraline plus placebo (n = 62). PMD was measured with the psychiatrist-rated sign-based CORE at acute phase baseline and at RCT baseline. Spearman's correlations and logistic regression analyses were used to analyze the association between CORE total score at acute phase baseline and remission/near-remission and CORE total score at RCT baseline and relapse.

RESULTS

Higher CORE total score at acute phase baseline was associated with lower frequency of remission/near-remission. Higher CORE total score at RCT baseline was associated with higher frequency of relapse, in the RCT sample as a whole, as well as in each of the two randomized groups.

CONCLUSIONS

PMD is associated with poorer outcome of psychotic depression treated with sertraline plus olanzapine. Future research needs to examine the neurobiology of PMD in psychotic depression in relation to treatment outcome.

Association of treatment facets, severity of manic symptoms, psychomotor disturbances and psychotic features with response to electroconvulsive therapy in bipolar depression

OBJECTIVES

Clinically useful predictors of response to electroconvulsive therapy (ECT) are warranted, especially in the case of bipolar depression. The aim of this study was to explore the associations between response and its known and putative correlates.

METHODS

Six hundred seventy bipolar depressive patients treated with ECT were included in the study. The association between response (CGI-I ≤ 2) and mean seizure duration, number of treatments, age, sex, bipolar subtype, episode duration, HAM-D and YMRS scores, psychomotor disturbances and psychotic symptoms assessed through BPRS-EV were evaluated by means of univariate and multivariate logistic regression models, including quadratic and/or linear effects of continuous variables.

RESULTS

Four hundred eighty three patients (72%) were responders. Among known correlates of response, significant quadratic effects were found for seizure duration and number of treatments, while a linear association was confirmed for episode duration. Among putative correlates, severe motor retardation, tension or agitation, hyperactivity and delusions of guilt were significantly associated with response (p<.01) and a significant quadratic effect was found for YMRS score (p<.01).

CONCLUSION

Bipolar depressive patients with severe psychomotor disturbances, mood-congruent delusions and severe mixed features are highly responsive to ECT. A significant improvement in response prediction is expected when considering those clinical characteristics.

A symptom-based approach in predicting ECT outcome in depressed patients employing MADRS single items

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.

The Combination of Serum BDNF, Cortisol and IFN-Gamma Can Assist the Diagnosis of Major Depressive Disorder

PURPOSE

Misdiagnosis and ineffective treatment are common in major depressive disorder (MDD) in current clinical practice, while the combination of various serum proteins may assist the correct diagnosis. The study aimed to explore whether the combination of serum inflammatory, stress, and neurotrophic factors could be helpful for the diagnosis of MDD and to investigate the predictors associated with early symptom improvements.

PATIENTS AND METHODS

Baseline serum levels of C-reactive protein (CRP), interleukin (IL)-6, IL-10, IL-1beta, tumor necrosis factor (TNF)-alpha, interferon (INF)-gamma, cortisol, and brain-derived neurotrophic factor (BDNF) were detected in 30 MDD patients and 30 age- and gender-matched healthy controls. 17-item Hamilton Depression Rating Scale (HAMD-17) and Hamilton Anxiety Rating Scale (HAMA) were applied to assess symptoms both at baseline and two weeks after antidepressant treatment. Stepwise multiple linear regression was employed to identify the early efficacy predictors, and a logistic regression model was built with the above serum proteins. The area under the receiver operating characteristic (AUC) curve was calculated to evaluate the model's diagnostic power.

RESULTS

Multiple linear regression revealed that baseline scores of retardation (β = -0.432, P = 0.012) and psychological anxiety (β = -0.423, P = 0.014) factors were negatively associated with the reduction rate of HAMD-17. A simple and efficient diagnostic model using serum BDNF, cortisol, and IFN-gamma levels was established by the forward stepwise logistic regression, and the model achieved an AUC of 0.884, with 86.7% sensitivity and 83.3% specificity.

CONCLUSION

The results showed that combining serum BDNF, cortisol and IFN-gamma could aid the diagnosis of MDD, while baseline retardation and psychological anxiety may predict the poor early symptom improvement.

Using EEG to Predict Clinical Response to Electroconvulsive Therapy in Patients With Major Depression: A Comprehensive Review

Introduction: An important approach to improve the therapeutic effect of electroconvulsive therapy (ECT) may be to early characterize patients who are more likely to respond. Our objective was to explore whether baseline electroencephalography (EEG) settings before the beginning of ECT treatment can predict future clinical response to ECT in patients with depressive disorder. Methods: We conducted a systematic search in the MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify studies using EEG in adults with depressive disorder treated by ECT. To investigate the predictive value of baseline EEG on clinical outcomes of ECT, we extracted from the retrieved studies and qualitatively described the association between the baseline EEG markers characteristics and the rates of future responders and/or remitters to ECT. Results: The primary search yielded 2,531 potentially relevant citations, and 12 articles were selected according to inclusion criteria. Most of the studies were prospective studies with small sample size. Sociodemographic and clinical characteristics of patients, ECT settings, EEG settings, and outcomes were heterogeneous. Event-related potential (ERP) paradigms were used in three studies, polysomnography was used in three studies, and the six other studies used EEG to measure cerebral connectivity and activity. Conclusions: P300 amplitude, coherence, and connectivity measures were correlated with remission in patients with depression treated by ECT. Sleep EEG recordings seemed not to be correlated with remission after ECT. Further prospective studies with large sample size are needed to determine optimal EEG parameters associated with clinical response to ECT in depressive disorder. Systematic Review Registration: PROSPERO CRD42020181978.

Electroconvulsive Therapy in Depression: Improvement in Quality of Life Depending on Age and Sex

OBJECTIVES

It is uncertain if there are variations in the improvement of quality in life between sexes and age groups after electroconvulsive therapy (ECT). The aim of this study was to investigate how health-related quality of life changed after treatment and to examine differences in the results between sex and age groups.

METHODS

This register-based study used data from the Swedish national quality register for ECT. The study population was patients diagnosed with depression who had received ECT. Health-related quality of life was quantified using the 3-level version the EuroQol 5-dimensional questionnaire (EQ-5D 3 L). Analysis of variance was used to compare change in EQ-5D score from pretreatment to posttreatment between sex and age groups.

RESULTS

There was a statistically significant improvement in EQ-5D index score and EQ visual analog scale (VAS) score in all patient groups after ECT. The mean improvement in EQ-5D index score and EQ-VAS score ranged from 0.31 to 0.46 and 28.29 to 39.79, respectively. Elderly patients had greater improvement in EQ-5D index score and EQ-VAS score than younger patients. There was no significant difference in improvement between the sexes. The mean improvement in EQ-5D index score was 0.40 for male patients and 0.41 for female patients.

CONCLUSIONS

Electroconvulsive therapy had a considerable effect on health-related quality of life in patients with depression of both sexes and all age groups. The improvement was greatest in elderly patients, who more often had psychotic features. More studies are needed to investigate the long-term effects of ECT and to further explain the varying treatment results between elderly and younger patients.

Psychomotor Retardation and the prognosis of antidepressant treatment in patients with unipolar Psychotic Depression

BACKGROUND

Psychomotor Retardation is a key symptom of Major Depressive Disorder. According to the literature its presence may affect the prognosis of treatment. Aim of the present study is to investigate the prognostic role of Psychomotor Retardation in patients with unipolar Psychotic Depression who are under antidepressant treatment.

METHODS

The Salpetriere Retardation Rating Scale was administered at baseline and after 6 weeks to 122 patients with unipolar Psychotic Depression who were randomly allocated to treatment with imipramine, venlafaxine or venlafaxine plus quetiapine. We studied the effects of Psychomotor Retardation on both depression and psychosis related outcome measures.

RESULTS

73% of the patients had Psychomotor Retardation at baseline against 35% after six weeks of treatment. The presence of Psychomotor Retardation predicted lower depression remission rates in addition to a higher persistence of delusions. After six weeks of treatment, venlafaxine was associated with higher levels of Psychomotor Retardation compared to imipramine and venlafaxine plus quetiapine.

CONCLUSIONS

Our data confirm that Psychomotor Retardation is a severity marker of unipolar Psychotic Depression. It is highly prevalent and predicts lower effectivity of antidepressant psychopharmacological treatment.

Psychotic late-life depression less likely to relapse after electroconvulsive therapy

BACKGROUND

A substantial number of patients with late-life depression (LLD) that remitted after ECT experience relapse. Identifying risk factors for relapse may guide clinical management to devote attention to those at increased risk. Therefore the current study aims to evaluate which baseline clinical characteristics are related to relapse within six months after successful ECT in patients with severe LLD.

METHODS

110 patients with LLD from the prospective naturalistic follow-up Mood Disorders in Elderly treated with Electro-Convulsive Therapy (MODECT) study were included. A total of 73 patients (66.4%) remitted after ECT, six patients had missing information on relapse, rendering to a total sample size of 67 patients. Relapse within six months after ECT was defined as a Montgomery Åsberg Depression Scale (MADRS)-score > 15, readmission or restart of ECT. Logistic regression analyses were conducted to examine the association between baseline clinical characteristics and relapse.

RESULTS

A total of 22 patients (32.8%) experienced a relapse. Patients with psychotic depression were less likely to relapse (odds ratio = 0.32, p = .047), corrected for prior admissions; 76.9% of patients with psychotic depression remained remitted.

LIMITATIONS

Due to its naturalistic design, no firm conclusions can be drawn on the effect of post-ECT treatment.

CONCLUSIONS

Patients with psychotic depression had a lower risk to experience relapse after successful ECT. This result strengthens the hypothesis that psychotic depression might be a specific depression subtype with a favorable ECT outcome up to six months after ECT.

When to consider electroconvulsive therapy (ECT)

OBJECTIVE

To familiarize the reader with the role of electroconvulsive therapy (ECT) in current psychiatric medicine.

METHOD

We review clinical indications for ECT, patient selection, contemporary ECT practice, maintenance treatment and ECT in major treatment guidelines.

RESULTS

ECT is underutilized largely due to persisting stigma and lack of knowledge about modern ECT technique.

CONCLUSION

ECT remains a vital treatment for patients with severe mood disorders, psychotic illness and catatonia.

Performance of the Psychotic Depression Assessment Scale as a Predictor of ECT Outcome

OBJECTIVES

The presence of psychotic symptoms is an important predictor of responsiveness to electroconvulsive therapy (ECT). This study investigates whether a continuous severity measure, the Psychotic Depression Assessment Scale (PDAS), is a more accurate predictor.

METHODS

Depression severity was assessed before and after the ECT course using the Montgomery-Asberg Depression Rating Scale (MADRS) in 31 patients with psychotic depression and 34 depressed patients without psychotic symptoms. Logistic regression models for MADRS response and remission were fitted, with either the PDAS total score or the dichotomous predictors "absence/presence of psychotic symptoms" as the independent variables. Age, episode duration, and treatment resistance were added as covariates.

RESULTS

Both the asserted presence of psychotic symptoms and a higher PDAS total score reflected MADRS response (areas under the curve, 0.83 and 0.85, respectively), with MADRS remission also being predicted by the presence of psychotic symptoms and higher PDAS scores (areas under the curves, 0.86 and 0.84, respectively). Age was a contributor to these prediction models, with response and remission rates being highest in the older patients. Psychotic Depression Assessment Scale scores decreased significantly during ECT: at end point, 81.5% of the patients showed significant response and 63.9% had achieved remission.

CONCLUSIONS

The PDAS indeed accurately predicts response to and remission after ECT in (psychotic) depression and most pronouncedly so in older patients but seems to have no clear advantage over simply verifying the presence of psychotic symptoms. This could be the consequence of a ceiling effect, as ECT was extremely effective in patients with psychotic depression.ClinicalTrials.gov: Identifier: NCT02562846.

Can psychomotor disturbance predict ect outcome in depression?

Psychomotor symptoms are core features of melancholic depression. This study investigates whether psychomotor disturbance predicts the outcome of electroconvulsive therapy (ECT) and how the treatment modulates psychomotor disturbance. In 73 adults suffering from major depressive disorder psychomotor functioning was evaluated before, during and after ECT using the observer-rated CORE measure and objective measures including accelerometry and a drawing task. Regression models were fitted to assess the predictive value of melancholic depression (CORE ≥ 8) and the psychomotor variables on ECT outcome, while effects on psychomotor functioning were evaluated through linear mixed models. Patients with CORE-defined melancholic depression (n = 41) had a 4.9 times greater chance of reaching response than those (n = 24) with non-melancholic depression (Chi-Square = 7.5, P = 0.006). At baseline, both higher total CORE scores (AUC = 0.76; P = 0.001) and needing more cognitive (AUC = 0.78; P = 0.001) and motor time (AUC = 0.76; P = 0.003) on the drawing task corresponded to superior ECT outcomes, as did lower daytime activity levels (AUC = 0.76) although not significantly so after Bonferroni correction for multiple testing. A greater CORE-score reduction in the first week of ECT was associated with higher ECT effectiveness. ECT reduced CORE-assessed psychomotor symptoms and improved activity levels only in those patients showing the severer baseline retardation. Although the sample was relatively small, psychomotor symptoms were clearly associated with beneficial outcome of ECT in patients with major depression, indicating that monitoring psychomotor deficits can help personalise treatment.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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