The Duration in Treatment With Electroconvulsive Therapy Among Patients Screening Positive or Negative for Borderline Personality Disorder Traits: A Retrospective Cohort Study

OBJECTIVE

While emerging evidence suggests that electroconvulsive therapy (ECT) is an effective treatment for depressive symptoms in patients with co-occurring borderline personality disorder (BPD) traits, it is unclear whether the presence of BPD traits modulates the tolerability of ECT. This study estimates the association between BPD traits and retention in acute course ECT treatment.

METHODS

This study used a retrospective cohort of patients receiving ECT between 2015 and 2020 and who were assessed using the McLean Screening Instrument for BPD, the Quick Inventory of Depressive Symptomatology Self-Report 16-item scale, and the Montreal Cognitive Assessment before initiating treatment.

RESULTS

One thousand five hundred eight patients received ECT during the study period, of whom 277 (18.4%) screened positive for BPD traits. Borderline personality disorder traits were associated with a higher odds of remaining in ECT for at least 10 treatments (adjusted odds ratio, 1.502; 95% confidence interval, 1.11-2.02; P = 0.007). Among individual symptom domains, only endorsing chronically feeling empty was associated with duration in ECT treatment.

CONCLUSIONS

Among patients receiving ECT, screening positive for BPD traits was associated with a higher odds of receiving at least 10 ECT treatments. These results support the overall tolerability of ECT in patients with BPD traits.

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.

Behavioral Therapy Teams for Obsessive-Compulsive Disorder: Lessons Learned From a Pilot Randomized Trial in a Community Mental Health Center

Community mental health centers (CMHCs) provide the majority of mental health services for low-income individuals in the United States. Exposure and response prevention (ERP), the psychotherapy of choice for obsessive-compulsive disorder (OCD), is rarely delivered in CMHCs. This study aimed to establish the acceptability and feasibility of testing a behavioral therapy team (BTT) intervention to deliver ERP in CMHCs. BTT consisted of individual information-gathering sessions followed by 12 weeks of group ERP and concurrent home-based coaching sessions. The sample consisted of 47 low-income individuals with OCD who were randomized to receive BTT or treatment as usual (TAU). Symptom severity and quality-of-life measures were assessed at pretreatment, posttreatment, and 3- and 6-month posttreatment. Feasibility of training CMHC staff was partially successful. CMHC therapists successfully completed rigorous training and delivered ERP with high fidelity. However, training paraprofessionals as ERP coaches was more challenging. ERP was feasible and acceptable to patients. BTT participants were more likely than TAU participants to attend their first therapy session and attended significantly more treatment sessions. A large between-group effect size was observed for reduction in OCD symptoms at posttreatment but differences were not maintained across 3- and 6-month follow-ups. For BTT participants, within-group effect sizes reflecting change from baseline to posttreatment were large. For TAU participants, depression scores did not change during the active treatment phase but gradually improved during follow-up. Results support feasibility and acceptability of ERP for this patient population. Findings also underscore the importance of implementation frameworks to help understand factors that impact training professionals.

Treatment Outcomes of Electroconvulsive Therapy for Depressed Patients With and Without Borderline Personality Disorder: A Retrospective Cohort Study

BACKGROUND

Electroconvulsive therapy (ECT) is the gold-standard treatment for refractory depression. Borderline personality disorder (BPD) is generally considered a poor predictor of treatment response. We sought to assess symptom-severity outcomes among depressed patients with (BPD+) and without (BPD-) comorbid BPD undergoing acute phase ECT.

METHODS

The study sample consisted of at least moderately depressed patients who received an acute course of ECT from January 2011 to December 2016 at an academic, freestanding psychiatric hospital. Participants completed a DSM-IV-validated BPD screening instrument at baseline. Measures of DSM-IV depressive symptom severity from the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) were taken serially on 4 occasions. Outcomes of interest comprised total QIDS-SR score trajectory, QIDS-SR suicidality subscore, and symptom cluster subscores posited to differentiate response among antidepressant treatments.

RESULTS

Of the 693 individuals who met study inclusion criteria, 145 (20.9%) screened positive for BPD. Overall, ECT was associated with significant improvement of depressive symptoms (χ²₁ = 504.8, P < .0001). Despite differing from BPD- individuals on key baseline features, BPD+ individuals responded to ECT with similar improvement in overall depression severity (χ²₁ = 0.22, P = .64), suicidality (χ²₁ = 1.63, P = .20), and core emotional (χ²₁ = 0.63, P = .43), sleep (χ²₁ = 0.20, P = .65), and atypical (χ²₁ = 1.30, P = .25) symptoms after 15 treatments. Post hoc analysis indicated a slightly less robust overall response among the BPD+ group by the 15th treatment.

CONCLUSIONS

Acute course ECT benefits depressed patients with or without comorbid BPD, although patients with BPD may exhibit less pronounced improvement over time.

Return to College After a First Episode of Psychosis

A first episode of psychosis (FEP) can derail a patient’s educational goals, including attainment of a college education, and this can have lasting ramifications for socioeconomic and health outcomes. Despite this, few studies have examined return to college, which is an important index of real-world educational success after a FEP. In this study, we conducted a longitudinal medical record review of patients in a transdiagnostic outpatient FEP program and performed survival analysis, setting return to college as the endpoint, among the subset of patients whose college education was interrupted. We found that 82% (93/114) of college-enrolled FEP individuals experienced disruptions to their education after FEP, but that return to college also occurred in a substantial proportion (49/88, 56%) among those on leave who had follow-up data. In this sample, the median time to college return was 18 months. When separated by baseline diagnostic category, FEP patients with affective psychotic disorders (FEAP, n = 45) showed faster time to college return than those with primary psychotic disorders (FEPP, n = 43) (median 12 vs 24 mo; P = .024, unadjusted). When adjusted for having no more than 1 psychiatric hospitalization at intake and absence of cannabis use in the 6 months prior to intake (which were also significant predictors), differences by diagnostic category were more significant (hazard ratio 2.66, 95% CI 1.43–4.94, P = .002). Participation in education is an important outcome for stakeholders, and students with FEP can be successful in accomplishing this goal.

5 Hz Repetitive transcranial magnetic stimulation for posttraumatic stress disorder comorbid with major depressive disorder

BACKGROUND

Standard clinical protocols for repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder (MDD) apply 10 Hz pulses over left prefrontal cortex, yet little is known about the effects of rTMS in more diagnostically complex depressed patients.

OBJECTIVE/HYPOTHESIS

Posttraumatic stress disorder (PTSD) is commonly comorbid with MDD, and while rTMS has been shown to alleviate PTSD symptoms in preliminary studies, ideal parameters remain unclear. We conducted a prospective, open-label study of 5 Hz rTMS for patients with comorbid PTSD + MDD and hypothesized stimulation would reduce symptoms of both disorders.

METHODS

Outpatients (N = 40) with PTSD + MDD and at least moderate global severity were enrolled. 5 Hz rTMS included up to 40 daily sessions followed by a 5-session taper. Symptoms were measured using the PTSD Checklist (PCL-5) and Inventory of Depressive Symptomatology, Self-Report (IDS-SR). Baseline-to-endpoint changes were analyzed.

RESULTS

The intent-to-treat population included 35 participants. Stimulation significantly reduced PTSD symptoms (PCL-5 baseline mean ± SD score 52.2 ± 13.1 versus endpoint 34.0 ± 21.6; p < .001); 23 patients (48.6%) met a pre-defined categorical PTSD response criteria. MDD symptoms also improved significantly (IDS-SR, baseline 47.8 ± 11.9 to endpoint 30.9 ± 18.9; p < .001); 15 patients (42.9%) demonstrated categorical response and 12 (34.3%) remitted. PTSD and MDD symptom change was highly correlated (r = 0.91, p < .001).

LIMITATIONS

Unblinded single-arm study, with modest sample size.

CONCLUSION

Significant and clinically meaningful reductions in both MDD and PTSD symptoms were observed following stimulation. The preliminary efficacy of 5 Hz rTMS for both symptom domains in patients with comorbid disorders supports future controlled studies.

A pilot randomized controlled trial of aerobic exercise as an adjunct to OCD treatment

OBJECTIVE

The purpose of the current study was to conduct a randomized controlled trial testing the efficacy of aerobic exercise for decreasing OCD symptom severity, other mental health outcomes, and increasing exercise behaviors and cardiorespiratory fitness among individuals with OCD.

METHOD

Fifty-six patients (64% female; mean age=38.8years) with OCD and a Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score of 16 or greater despite engaging in OCD treatment were randomized to 12-weeks of supervised plus home-based moderate-intensity aerobic exercise (AE; n=28) or to 12-weeks of health education sessions (HE; n=28).

RESULTS

Random intercepts mixed models examined differences between conditions at post-treatment. Though no difference between conditions on outcomes was observed, both AE and HE showed significant reduction in OCD symptom severity, depression and anxiety at post-treatment. Relative to HE, significant increases were noted in amount of exercise and cardiorespiratory fitness for those in the AE condition. At post-treatment, 30.4% of the AE condition (7 of 23) were treatment-responders (using the commonly accepted measure of 35% symptom reduction from baseline). In the HE condition, 7.7% of the sample (2 of 26) met this criterion at post-treatment.

CONCLUSION

The results of this preliminary study suggest that exercise and health-focused interventions may be beneficial adjuncts to existing OCD treatment. Future studies with larger samples are needed to more definitively answer questions the efficacy of AE for reducing OCD symptoms and improving related clinical outcomes.

Transcranial magnetic stimulation for treatment-resistant depression: Naturalistic treatment outcomes for younger versus older patients

BACKGROUND

Repetitive transcranial magnetic stimulation (TMS) has been shown to be safe and effective for treatment-resistant depression (TRD) in the general adult population. Efficacy among older (≥60 years) patients, who have a greater burden of cognitive, physical, and functional impairment compared to their younger counterparts, remains unclear. The current study aimed to characterize antidepressant response to an acute course of TMS therapy among patients aged ≥60 years compared to those <60 years in naturalistic clinical practice settings.

METHODS

Data were retrospectively collected and pooled for adults with TRD (N =231; n =75 aged ≥60 years and n = 156 <60 years) who underwent an acute course of outpatient TMS therapy at two outpatient clinics. Self-report depression scales were administered at baseline and end of acute treatment. Change on continuous measures and categorical outcomes were compared across older vs. younger patients.

RESULTS

Both age groups showed significant improvements in depression symptoms. Response and remission rates did not differ between groups. Age group was not a significant predictor of change in depression severity, nor of clinical response or remission, in a model controlling for other predictors (all p>.05).

LIMITATIONS

Limitations include reliance on self-report clinical measures and variability in comorbidity and concurrent pharmacotherapy due to the naturalistic nature of the study.

CONCLUSIONS

Results suggest that effectiveness of TMS for TRD is not differentially modified by age. Based on these naturalistic data, age alone should not be considered a contraindication or poor prognostic indicator of the antidepressant efficacy of TMS.

61% of unmedicated treatment resistant depression patients who did not respond to acute TMS treatment responded after four weeks of twice weekly deep TMS in the Brainsway pivotal trial

BACKGROUND

An acute course of dTMS typically involves treatments delivered 5 days a week, for 4 weeks. Should more treatments be given if the patient has not responded? Data are needed to inform decisions about the best next steps for acute non-responders.

OBJECTIVE

To characterize response among acute-phase non-responders in a randomized controlled trial of deep repetitive transcranial magnetic stimulation (dTMS) monotherapy for medication-resistant depression.

METHODS

Summary statistics and Kaplan-Meier curves were used to characterize outcomes of 33 medication-free Brainsway™ dTMS non-responders to double blind but active treatment at the end of 4 weeks (20 sessions), who then continued double blind but active twice-weekly treatment for up to 12 additional weeks.

RESULTS

24 participants (72.7%) achieved responder status during at least one rating with dTMS continuation -- 20 (60.6%) within four weeks, with 13 (39.4%) consistently meeting response criteria for the duration of the study. 20 (63.6%) achieved remission status at some point during treatment continuation.

CONCLUSIONS

A significant proportion of acute course non-responders to dTMS treatment eventually respond with continued treatment. Continuing TMS treatment beyond the acute course for non-responders may result in eventual response in over half of these individuals.

Risk factors for incident dementia in England and Wales: The Medical Research Council Cognitive Function and Ageing Study. A population-based nested case-control study

OBJECTIVE

To investigate a number of prospectively collected factors (sociodemographic, medical and behavioural) and their association with incident dementia in a population-based cohort.

DESIGN

Nested case-control analysis (at 2 and 6 years) of a population-based cohort study.

SETTING

Individuals aged 65 years and above from five centres in England and Wales: two rural (Cambridgeshire and Gwynedd) and three urban (Nottingham, Newcastle and Oxford).

PARTICIPANTS

A total of 4,075 individuals from a detailed assessment group, with risk measured at baseline.

MAIN OUTCOME MEASURE

Incident dementia at 2 and 6 years.

METHODS

Logistic regression was used to calculate crude odds ratios (ORs) for various risk factors and ORs adjusted for age, sex, education and social class.

RESULTS

Age (90+ versus 65-69 years OR = 25.6, 95% confidence interval (CI) = 11.6-56.9) and sex (women versus men OR = 1.6, 95% CI = 1.1-2.4) were directly associated with dementia, with a trend by years of education (P(trend) = 0.02) but not social class. Poor self-perceived health (versus good) increased the risk for incident dementia (OR = 3.9, 95% CI = 2.2-6.9). Alcohol and smoking (never, past and current) were neither strongly protective nor predictive. Stroke was strongly related to incident dementia (OR = 2.1, 95% CI = 1.1-4.2), as was Parkinson's disease (OR = 3.5, 95% CI = 1.3-9.3), and exposure to general anaesthesia (GA) was inversely associated with dementia development (OR = 0.6, 95% CI = 0.4-0.9, with a trend with increasing GA exposure; P = 0.003).

CONCLUSION

In this large multicentre and long-term population-based study, some well-known risk factors for dementia, of vascular and Alzheimer's type, are confirmed but not others. The association between self-perceived health-a robust predictor of later health outcomes-and incident dementia, independently of other potential risks, warrants further study.

APOE, vascular pathology, and the AD brain

OBJECTIVE

To use neuropathologic data to examine the association between APOE genotype and cerebrovascular lesions commonly found in Alzheimer disease (AD), as well as neuritic senile plaque (SP) and neurofibrillary tangle (NFT) burden.

METHODS

The sample comprised brains from 96 men and 3 women who fulfilled NIA-Reagan criteria for intermediate to high likelihood of AD. Region-specific and global measures of gross cerebrovascular disease, arteriolosclerosis, white matter lesions, microinfarcts, amyloid angiopathy, neuritic SP, and NFT burden were compared among those who had at least one APOE-epsilon4 vs those who did not. Pairwise rank-order correlations between measures were calculated. The association between APOE epsilon4 status and measures of vascular and AD pathology, adjusting for age at death, sex, brain weight, and Braak stage, were evaluated.

RESULTS

APOE-epsilon4 was not associated with gross cerebrovascular pathology. Compared to those who were negative, brains from epsilon4 individuals had a greater degree of small vessel arteriolosclerosis (p = 0.04) and perivascular macrophage infiltration (p = 0.06), but not other markers of small vessel disease or white matter myelin loss. Microinfarcts in the deep nuclei were associated with epsilon4 (p = 0.009), whereas cortical and subcortical microinfarcts were not. There was a trend toward association between APOE genotype and amyloid angiopathy (p = 0.08), and epsilon4 was associated with neuritic SP burden, but not NFT.

CONCLUSION

APOE-epsilon4 is associated with small vessel arteriolosclerosis, microinfarcts of the deep nuclei, neuritic senile plaque density, and amyloid angiopathy in patients with autopsy-proven Alzheimer disease (AD). These results suggest a role for epsilon4 in some of the microvascular changes commonly found in AD and are consistent with a potential amyloidogenic role for epsilon4.

Search for genetic factors predisposing to atherogenic dyslipidemia

Background

Atherogenic dyslipidemia (AD) is a common feature in persons with premature coronary heart disease. While several linkage studies have been carried out to dissect the genetic etiology of lipid levels, few have investigated the AD lipid triad comprising elevated serum triglyceride, small low density lipoprotein (LDL) particles, and reduced high density lipoprotein (HDL) cholesterol levels. Here we report the results of a whole-genome screen for AD using the Framingham Heart Study population.

Results

Our analyses provide some evidence for linkage to AD on chromosomes 1q31, 3q29, 10q26, 14p12, 14q13, 16q24, 18p11, and 19q13.

Conclusion

AD susceptibility is modulated by multiple genes in different chromosomes. Our study confirms results from other populations and suggests new areas of potential importance.

Genome-wide screen for heavy alcohol consumption

Background

To find specific genes predisposing to heavy alcohol consumption (self-reported consumption of 24 grams or more of alcohol per day among men and 12 grams or more among women), we studied 330 families collected by the Framingham Heart Study made available to participants in the Genetic Analysis Workshop 13 (GAW13).

Results

Parametric and nonparametric methods of linkage analysis were used. No significant evidence of linkage was found; however, weak signals were identified in several chromosomal regions, including 1p22, 4q12, 4q25, and 11q24, which are in the vicinity of those reported in other similar studies.

Conclusion

Our study did not reveal significant evidence of linkage to heavy alcohol use; however, we found weak confirmation of studies carried out in other populations.

Apolipoprotein E4 is only a weak predictor of dementia and cognitive decline in the general population

BACKGROUND

Apolipoprotein E (APOE) polymorphisms are unequivocally associated with risk for Alzheimer's disease (AD). It is crucial to understand how this genetic factor affects dementia risk in the general population, as well as in narrowly diagnosed, selected, patient groups.

METHODS

We assessed the cross sectional association between APOE genotype and dementia status in a community based sample, the MRC Cognitive Function and Ageing Study (MRC CFAS). In addition, we tested the effects of APOE genotypes on the differences in MMSE scores between the first and third assessment waves (about six years apart), an index of cognitive decline.

RESULTS

The APOE epsilon4 allele conferred increased risk for dementia (OR=1.5, 95% CI=1.1 to 2.2) compared to epsilon3 in the MRC CFAS sample. Compared with APOE epsilon3/epsilon 3 subjects, those with the epsilon3/epsilon4 genotypes were not at significantly higher risk for dementia (OR=1.1, 95% CI=0.6 to 1.9), although epsilon4/epsilon4 subjects were (OR= 3.8, 95% CI=1.0 to 14.0). Risk estimates were not different between men and women. Notably, our risk estimates for dementia were significantly lower than those reported for a diagnosis of Alzheimer's disease. MMSE scores at wave 3 and the difference in MMSE between baseline and at the third assessment wave were not different across APOE genotypes.

INTERPRETATION

The APOE epsilon4 allele is a weaker predictor for dementia in the general population than for AD. This may be because dementia can be caused by non-AD pathological processes and because most prevalent dementia occurs at an age when the APOE epsilon4 effect on AD risk (and therefore dementia) has started to decline.