[Successful treatment with ECT of comorbid psychotic depression in Segawa syndrome]

We report the case of a 70-year-old man with Segawa syndrome who achieved full remission in three episodes of psychotic depression following electroconvulsive therapy (ECT). As maintenance drug therapy was unable to prevent relapse, maintenance ECT seemed necessary. Segawa syndrome is a rare metabolic disorder characterized by dystonia and possibly psychiatric symptoms. We highlight the psychiatric vulnerability of patients with Segawa syndrome and point out some considerations in treating comorbid psychiatric disorders.

Contributions of age and clinical depression to metacognitive performance

One aspect of metacognition is the ability to judge the accuracy of our own performance, even in the absence of external feedback, which is often measured using confidence ratings. Past research suggests that confidence is lower in Major Depressive Disorder (MDD). Less is known about the ability of MDD patients to discriminate correct from incorrect performance (metacognitive efficiency). The metacognitive performance of aged MDD patients (62-89y) was compared to an age-matched control group. A younger control group (21-28y) was included to also explore the relationshipbetweenageandmetacognitive performance. We found no difference in confidence bias nor metacognitive efficiency between MDD patients and age-matched controls.We found age-related differences in metacognition:normal aging was associated with higher confidencebut lower metacognitive efficiency. The overconfidence was specifically driven by overconfidence in incorrect trials. Our results point to the importance ofage while investigating the relation between MDD and metacognitive performance.

[The impact of electroconvulsive therapy on the duration of elderly inpatient hospitalisation: a retrospective chart review]

Reducing the length of hospital stay (lohs) of elderly psychiatric patients is of great importance. The role of electroconvulsive therapy (ect) in this process is still unclear.<br/> AIM: To explore the impact of ect on the lohs in elderly (>60 years) with major depressive disorder (mdd).<br/> METHOD: All charts of patients with a diagnosis of mdd, discharged from geriatric psychiatry wards from April 2009 to December 2017 were gathered. Two groups were further explored: those who did not receive ect although available (no-ect; n = 170) and those who received ect within 3 weeks of admission (ect<3wks; n = 60). As primary outcome measure lohs was used.<br/> RESULTS: No significant difference in lohs was observed between the no-ect group and the ect< 3wks group (mean 90.3 (sd: 109.2) and 86.4 (sd: 70.9) days; p=0.798). The distribution of diagnoses in the groups was significantly different (p<0.001) with psychotic features in 35.2% of patients in the no-ect group and 72% in the ect<3wks group. CONCLUSIONS Electroconvulsive therapy did not significantly change lohs in elderly with mdd. Time until starting ect and the presence of psychotic features appear to be important confounders that need to be taken into account in further research.

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.

[Psychotic depression in older adults: an overview]

Psychotic depression is a frequent, severe psychiatric condition in older depressive inpatients aged 60 years and older. Older adults with a psychotic depression exhibit specific symptoms that are different from those in younger adults with psychotic depression. Moreover, the symptoms are also different from those in older adults  with a major depression without psychotic features. The recommended treatment consists of a tricyclic antidepressant, with or without addition of an antipsychotic, or electroconvulsive therapy. These treatments may however produce significant side effects that require intensive monitoring. In this article we present an overview of clinical topics regarding the diagnosis and treatment of older people with a psychotic depression.

Abstract P5-14-13: An observational study using g-H2AX foci to investigate cardiac doses of radiation in women following adjuvant radiotherapy for breast cancer: External beam radiotherapy versus targeted intraoperative radiotherapy

Background

External beam radiotherapy (EBRT) is the gold standard adjuvant treatment after breast conserving surgery for localised breast cancer. A recent phase 3 trial has shown the non-inferiority of intraoperative radiotherapy (IORT) compared with EBRT in terms of short-term safety and efficacy (TARGIT A Trial; Lancet 2010). IORT also has advantages in cost saving and patient convenience.

Radiation exposure of the heart and cardiac vessels is associated with an increase in morbidity and mortality following EBRT for breast cancer and has been shown to increase the rate of major coronary events by 7.4% per gray of exposure to the heart (Darby; NEJM 2013). IORT uses low energy x-rays (50 kV) and is likely to reduce the radiation exposure of the cardiovascular system compared with EBRT.

We have used γ-H2AX foci formation in peripheral blood lymphocytes as a surrogate marker of radiation dose to the heart and great vessels. The phosphorylated histone H2AX protein (γ-H2AX) is expressed after induction of DNA double strand breaks caused by ionising radiation, created as the lymphocytes pass through and adjacent to the irradiated field.

Methods

34 patients were recruited, having either EBRT or IORT as part of a randomised controlled trial. The main inclusion criteria were adult females with early breast cancer suitable for breast conserving surgery and the main exclusion criteria were previous malignancy, recent exposure to radiation (excluding CT planning scan) and prior chemotherapy. Blood samples were taken immediately prior to and 30 minutes after either first fraction of EBRT or after IORT treatment, and then rapidly processed to allow quantification of the γ-H2AX biomarker in lymphocytes (Rothkamm; Radiology 2007). This study had approval from the Local Research and Ethics Committee.

Results

Data were available for 31 patients. Means and standard deviations for the change in γ-H2AX foci number per cell for each group are summarised in table 1. Following IORT there was an increase of 0.203 foci per cell (range -1.436 to 1.275) compared with an increase of 0.935 foci per cell (range -0.679 to 2.216) in the EBRT group; this difference was highly significant (p = 0.009).

Table 1: γ-H2AX foci per cell IORTEBRTMean0.2030.935SD0.6330.764n1318

Conclusions

These data show a significantly greater change in γ-H2AX foci number per cell following one fraction of EBRT compared to IORT. IORT is a single treatment (20Gy at the applicator surface) whereas EBRT is repeated 15 times (2.67Gy x 15 fractions) multiplying the effect on the patients’ cardiovascular system.

It may be hypothesised that this reduced radiotherapy dose from IORT will reduce the risk of cardiovascular morbidity and mortality compared to EBRT. This is the first study to demonstrate the real time effect of radiotherapy to the heart and great vessels using a biomarker and demonstrates a proof of concept methodology for similar applications.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-14-13.

Psychomotor changes in major depressive disorder during sertraline treatment

BACKGROUND

There is a relative scarcity of studies on major depressive disorder that use objective assessment methods to explore the psychomotor effects of antidepressants. Striatal dopaminergic disturbances are known to be involved in the pathogenesis of major depressive disorder that is associated with psychomotor retardation. Because of its additional dopaminergic mechanism, the psychomotor effects of the selective serotonin reuptake inhibitor sertraline merit further exploration.

METHODS

In 19 patients diagnosed with a current major depressive episode, clinical variables and graphic motor activity were assessed applying digitized figure copying tasks during a 6-week regimen of sertraline. Patients' baseline and weekly psychomotor performance was compared with the outcomes of 22 healthy, unmedicated controls.

RESULTS

Patients' psychomotor slowing had improved after 6 weeks on sertraline as reflected by reductions in initiation and movement times on the simple line and figure copying tasks and decreased initiation times for the complex figure copying task relative to their baseline outcomes.

CONCLUSIONS

The current study found evidence pointing to potential beneficial effects of sertraline after a 6-week treatment period in the lower-order cognitive and motor components involved in the graphic motor performance of depressed patients. The present findings are discussed in terms of the mechanism of action of sertraline.

Delineating psychomotor slowing from reduced processing speed in schizophrenia

INTRODUCTION

Psychomotor slowing is an intrinsic feature of schizophrenia that is poorly delineated from generally reduced processing speed. Although the Symbol Digit Substitution Test (SDST) is widely used to assess psychomotor speed, the task also taps several higher-order cognitive processes. Recording motor performance on copying tasks using a digitising tablet allows a more precise measurement of psychomotor speed.

METHODS

A group of 75 schizophrenic inpatients were compared to 26 healthy controls in their performance on the SDST and two copying tasks.

RESULTS

Factor analyses showed that the copying tasks were found to capture both a cognitively loaded factor and the motor component of psychomotor slowing better, which latter aspect is not properly assessed by the SDST.

CONCLUSIONS

In schizophrenia psychomotor slowing seems to exist alongside reduced processing speed.

[Cotard's syndrome. Different treatment strategies according to subclassification]

After performing an exploratory factor analysis, Berrios & Luque (1995) identified three subcategories in the Cotard's syndrome: Cotard type I, Cotard type II and Cotard type psychotic depression. The article, which is based on two case studies and an examination of the relevant literature since 1995, explores whether there are different treatment strategies for Cotard type I and the Cotard type psychotic depression. For the Cotard type psychotic depression, electroconvulsive therapy proves to be an effective method of treatment. For Cotard type I, antipsychotic therapy seems to be sufficient.