Ketamine for major depressive disorder during an inpatient psychiatric admission: Effectiveness, adverse events, and lessons learned

OBJECTIVE

Most studies examining the efficacy of ketamine for Major Depressive Disorder (MDD) have been conducted in outpatient or mixed inpatient/outpatient settings. Less is known about effectiveness and tolerability of ketamine for psychiatrically hospitalized patients. Efficacy and tolerability data from a naturalistic sample of acute inpatients may help inform institutions considering ketamine therapy for inpatient services.

METHODS

We performed a retrospective chart review of inpatients with non-psychotic MDD treated during the initial 3 years of a ketamine infusion program. Treatment effectiveness was defined using change in Montgomery Asberg Depression Rating Scale (MADRS) scores over five infusions. MDD treatment response was defined by a 50 % reduction of MADRS score, and remission was defined as MADRS score ≤ 10 at any point during the treatment. We also report the frequency of adverse events.

RESULTS

41 patients with MDD were treated and had outcome data. 19 patients (46.5 %) met criteria for response and 15 patients (26.5 %) met criteria for remission during treatment. Four patients (10 %) had adverse psychological or behavioral outcomes.

LIMITATIONS

MADRS scales were administered by psychiatrists, psychologists, and trainees in each discipline who did not undergo standardized training in scale administration. Consistent data regarding the race/ethnicity of the patients was not available.

CONCLUSION

Twice weekly racemic ketamine infusion is an effective treatment option for patients hospitalized with MDD. Unmonitored or at home ketamine therapy may pose substantial risks.

The clinical effectiveness of a self-management intervention for patients with persistent depressive disorder and their partners/caregivers: results from a multicenter, pragmatic randomized controlled trial

BACKGROUND

Persistent depressive disorder (PDD) is prevalent and debilitating. For patients with PDD, psychiatric rehabilitation using self-management interventions is advised as the next therapeutic step after multiple unsuccessful treatment attempts. The "Patient and Partner Education Program for All Chronic Diseases" (PPEP4All) is a brief, structured self-management program that focuses on functional recovery for patients and their partners/caregivers. In chronic somatic disorder populations, PPEP4All has already been shown to be clinically effective. We examined whether PPEP4All adapted for PDD (PPEP4All-PDD, nine weekly group or individual sessions) is also clinically effective for adults/elderly with PDD and their partners/caregivers compared to care-as-usual (CAU) in specialized mental healthcare.

METHODS

In this mixed-method multicenter pragmatic randomized controlled trial, 70 patients with PDD and 14 partners/caregivers were allocated to either PPEP4All-PDD (patients, n = 37; partners/caregivers, n = 14) or CAU (patients, n = 33; partners/caregivers, not included) and completed questionnaires at 0, 3, 6, and 12 months regarding depressive symptoms, psychopathology, psychosocial burden, mental resilience, and happiness/well-being. Qualitative data were collected regarding treatment satisfaction. Data were analyzed using mixed model analyses and an intention-to-treat (ITT) approach.

RESULTS

There was no statistically significant difference in any outcome regarding clinical effectiveness between PPEP4All-PDD and CAU. Subgroup analysis for depressive symptoms did not show any interaction effect for any subgroup. Although 78% of participants recommended PPEP4All-PDD, there was no difference in treatment satisfaction between PPEP4All-PDD (score = 6.6; SD = 1.7) and CAU (score = 7.6; SD = 1.2), p = 0.06.

CONCLUSION

Although depressive symptoms did not improve relative to CAU, this only confirmed that treatment for patients with treatment-resistant PDD should move from symptom reduction to functional recovery. Also, functional recovery may be reflected in other outcomes than psychosocial burden, such as self-empowerment, in patients with treatment-resistant PDD. Future research on PPEP4All-PDD could focus on a longer-term program and/or online program that may also be offered earlier in the treatment process as an empowerment intervention.  TRIAL REGISTRATION: Netherlands Trial Register Identifier NL5818. Registered on 20 July 2016 https://clinicaltrialregister.nl/nl/trial/20302.

Hippocampal volume changes after (R,S)-ketamine administration in patients with major depressive disorder and healthy volunteers

The hippocampus and amygdala have been implicated in the pathophysiology and treatment of major depressive disorder (MDD). Preclinical models suggest that stress-related changes in these regions can be reversed by antidepressants, including ketamine. Clinical studies have identified reduced volumes in MDD that are thought to be potentiated by early life stress and worsened by repeated depressive episodes. This study used 3T and 7T structural magnetic resonance imaging data to examine longitudinal changes in hippocampal and amygdalar subfield volumes associated with ketamine treatment. Data were drawn from a previous double-blind, placebo-controlled, crossover trial of healthy volunteers (HVs) unmedicated individuals with treatment-resistant depression (TRD) (3T: 18 HV, 26 TRD, 7T: 17 HV, 30 TRD) who were scanned at baseline and twice following either a 40 min IV ketamine (0.5 mg/kg) or saline infusion (acute: 1-2 days, interim: 9-10 days post infusion). No baseline differences were noted between the two groups. At 10 days post-infusion, a slight increase was observed between ketamine and placebo scans in whole left amygdalar volume in individuals with TRD. No other differences were found between individuals with TRD and HVs at either field strength. These findings shed light on the timing of ketamine's effects on cortical structures.

Refractory Depression With Persistent Sore Throat and Hypochondriacal Delusion of SARS-CoV-2 Infection: A Case Study

ABSTRACT

Herein, we present a case of a female patient with a persistent sore throat, which preceded a hypochondriacal delusion of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Both the sore throat and hypochondriacal delusion persisted together, despite the repeatedly negative results of reverse transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 and a moderate improvement in her depression. Four possibilities for the patient's sore throat were discussed: pain symptoms of somatic symptom disorder, pain symptoms of depression, delusion of pain in her throat, and somatic hallucination as a sore throat. Consequently, somatic hallucinations were considered the most likely. In any case, the present findings suggest that sore throat can precede hypochondriacal delusion of SARS-CoV-2 infection in some noninfected patients. When patients continue to complain of a sore throat despite the negative results of SARS-CoV-2 by the RT-PCR test, we should consider that it might be a somatic hallucination and soon hypochondriacal delusions may occur, leading to the manifestation of other symptoms of psychiatric disorders, such as depression, which may be refractory and/or suicidal.

Anesthetic Management of Patients Undergoing Electroconvulsive Therapy

Electroconvulsive Therapy (ECT) is an effective treatment for mood disorders, particularly treatment-resistant depression, and several psychiatric illnesses. Anesthetic management of patients undergoing ECT requires an understanding of ECT, the physiologic changes induced by electrical stimulus, the anesthetic agents used, and the potential complications associated with the procedure. Numerous medical and surgical conditions can impact procedural approach and anesthetic management. ECT is challenging due to its typically off-site location, fast-paced general anesthesia with bag-mask ventilation, selection of anesthetic agents that minimally affect the seizure, patient's comorbidities, and unique physiologic responses. This comprehensive review aims to update anesthetists on the periprocedural management of patients undergoing ECT.

Brain-Derived Neurotrophic Factor (BDNF) as a Predictor of Treatment Response in Major Depressive Disorder (MDD): A Systematic Review

Brain-derived neurotrophic factor (BDNF) has been studied as a biomarker of major depressive disorder (MDD). Besides diagnostic biomarkers, clinically useful biomarkers can inform response to treatment. We aimed to review all studies that sought to relate BDNF baseline levels, or BDNF polymorphisms, with response to treatment in MDD. In order to achieve this, we performed a systematic review of studies that explored the relation of BDNF with both pharmacological and non-pharmacological treatment. Finally, we reviewed the evidence that relates peripheral levels of BDNF and BDNF polymorphisms with the development and management of treatment-resistant depression.

Irremediability in psychiatric euthanasia: examining the objective standard

BACKGROUND

Irremediability is a key requirement for euthanasia and assisted suicide for psychiatric disorders (psychiatric EAS). Countries like the Netherlands and Belgium ask clinicians to assess irremediability in light of the patient's diagnosis and prognosis and 'according to current medical understanding'. Clarifying the relevance of a default objective standard for irremediability when applied to psychiatric EAS is crucial for solid policymaking. Yet so far, a thorough examination of this standard is lacking.

METHODS

Using treatment-resistant depression (TRD) as a test case, through a scoping review in PubMed, we analyzed the state-of-the-art evidence for whether clinicians can accurately predict individual long-term outcome and single out irremediable cases, by examining the following questions: (1) What is the definition of TRD; (2) What are group-level long-term outcomes of TRD; and (3) Can clinicians make accurate individual outcome predictions in TRD?

RESULTS

A uniform definition of TRD is lacking, with over 150 existing definitions, mostly focused on psychopharmacological research. Available yet limited studies about long-term outcomes indicate that a majority of patients with long-term TRD show significant improvement over time. Finally, evidence about individual predictions in TRD using precision medicine is growing, but methodological shortcomings and varying predictive accuracies pose important challenges for its implementation in clinical practice.

CONCLUSION

Our findings support the claim that, as per available evidence, clinicians cannot accurately predict long-term chances of recovery in a particular patient with TRD. This means that the objective standard for irremediability cannot be met, with implications for policy and practice of psychiatric EAS.

Psychedelics, With a Focus on Psilocybin: Issues for the Clinician

There has been a burgeoning interest in psychedelics among the public, state legislatures, psychiatrists and other clinical providers, and within the research community. Increasing numbers of studies evaluating psychedelics for depression, anxiety, posttraumatic stress disorder, and substance use disorders have been conducted or are underway. While discussing psychedelics in general, the focus of this paper is on psilocybin and its mechanism, how it exerts a psychedelic effect, dosing, and a review of the treatment studies of psilocybin, which were primarily for treatment-resistant depression and cancer-related anxiety. Future directions and potential limitations of studying and regulating psilocybin and other psychedelics are also discussed.

Accelerated intermittent theta burst stimulation in major depressive disorder: A systematic review

BACKGROUND

Major depressive disorder [MDD] is expected to be the leading cause of overall global burden of disease by the year 2030 [WHO]. Non-response to first line pharmacological and psychotherapeutic antidepressive treatments is substantial, with treatment-resistant depression [TRD] affecting approximately one third of depressed patients. There is an urgent need for rapid acting and effective treatments in this population. Repetitive Transcranial Magnetic Stimulation [rTMS] is an non-invasive treatment option for patients with MDD or TRD. Recent studies have proposed new paradigms of TMS, one paradigm is accelerated intermittent Theta Burst Stimulation [aiTBS].

OBJECTIVE

This systematic review assesses the efficacy, safety and tolerability of aiTBS in patients with MDD.

METHODS

This review was registered with PROSPERO [ID number: 366556]. A systematic literature review was performed using Pubmed, Web of Science and PsycINFO. Case reports/series, open-label and randomized controlled trials [RCTs] were eligible for inclusion if they met the following criteria; full text publication available in English describing a form of aiTBS for MDD or TRD. aiTBS was defined as at least three iTBS treatments sessions per day, during at least four days for one week.

RESULTS

32 studies were identified describing aiTBS in MDD, 13 studies described overlapping samples. Six articles from five unique studies met eligibility criteria; two open-label studies and three RCTs [two double blind and one quadruple blind]. Response rates directly after treatment ranged from 20.0% to 86.4% and remission rates ranged from 10.0 to 86.4%. Four weeks after treatment response rates ranged from 0.0% to 66.7% and remission rates ranged from 0.0% to 57.1%. Three articles described a significant reduction in suicidality scores. aiTBS was well tolerated and safe, with no serious adverse events reported.

CONCLUSIONS

aiTBS is a promising form of non-invasive brain stimulation [NIBS] with rapid antidepressant and antisuicidal effects in MDD. Additionally, aiTBS was well tolerated and safe. However, the included studies had small samples sizes and differed in frequency, intersession interval, neuro localization and stimulation intensity. Replication studies and larger RCTs are warranted to establish efficacy, safety and long term effects.

A unified model of the biology of peripartum depression

Peripartum depression (PPD) is a prevalent and debilitating disorder that adversely affects the development of mothers and infants. Recently, there has been a plea for increased mental health screening during the peripartum period; however, currently, there is no accurate screening tool to identify women at risk of PPD. In addition, some women do not respond to current treatment schemes and develop treatment-resistant depression. The current perspective aims to propose a unified understanding of the biological underpinnings of PPD (UmPPD) that considers the heterogeneity in the onset, symptoms cluster, and severity of PPD. Such a model could promote basic and applied research on PPD and suggest new treatment avenues. The central hub of the model is the kynurenine pathway (KP) and the KP-serotonin ratio. The forces and specific processes at play that cause an imbalance within the KP and between KP and serotonin are inflammation, stress, reproductive hormones (especially estradiol and progesterone), and oxytocin. UmPPD predicts that the most severe PPD would comprise prolonged inflammation, ongoing or multiple stressors, excessive estrogen, progesterone resistance, and avoidance of breastfeeding, skin-to-skin contact, and social proximity. These factors would be associated with a higher likelihood of developing PPD, early onset, and more significant symptom severity. In addition, subtypes of PPD would consist of different compositions and expressions of these components, with one central common factor. UmPPD could aid in directing future research and possibly detecting critical processes that could help discover, develop, and utilize novel treatments for PPD.

Observational study to characterize treatment-resistant depression in Germany, France and the United Kingdom: analysis of real-world data collected through a survey of healthcare professionals

OBJECTIVE

This study describes treatment patterns, productivity, healthcare resource utilization and previous episodes of depression for patients with treatment-resistant depression (TRD).

METHODS

In this cross-sectional study, a quantitative survey was administered to 225 healthcare providers (HCPs) distributed evenly across Germany, France and the UK from July to August 2021. Each HCP was asked to answer based on medical records of five patients with TRD, defined as patients failing to respond to two or more treatments of adequate dose and duration in the same episode of major depressive disorder (MDD), which provided a sample size of 1125 patients.

RESULTS

Of the 1125 patients with TRD, 73.2% had two or more previous episodes of MDD, 46.3% had a history of suicidal ideation and 24.8% had attempted suicide. Only 26.8% of patients were employed either full-time or part-time. During the most recent/current TRD episode, 45.5% of patients received five or more lines of treatment, and 46.0% remained on monotherapy. For multiple pharmacological treatments, too many distinct combinations were used to discern trends. Overall, 60.6% of patients had at least one mental health-related hospitalization in the last 12 months; 35.0% had two or more hospitalizations. Half of TRD patients saw a doctor five or more times per year for their depression.

CONCLUSIONS

This study addresses the knowledge gap about treatment patterns and healthcare utilization in real-world practice for TRD patients in three European countries. It provides data that potentially could inform treatment guideline development and optimize patient-perceived benefits from the treatment of TRD.

National Network of Depression Centers' Recommendations on Harmonizing Clinical Documentation of Electroconvulsive Therapy

ABSTRACT

Electroconvulsive therapy (ECT) is a highly therapeutic and cost-effective treatment for severe and/or treatment-resistant major depression. However, because of the varied clinical practices, there is a great deal of heterogeneity in how ECT is delivered and documented. This represents both an opportunity to study how differences in implementation influence clinical outcomes and a challenge for carrying out coordinated quality improvement and research efforts across multiple ECT centers. The National Network of Depression Centers, a consortium of 26+ US academic medical centers of excellence providing care for patients with mood disorders, formed a task group with the goals of promoting best clinical practices for the delivery of ECT and to facilitate large-scale, multisite quality improvement and research to advance more effective and safe use of this treatment modality. The National Network of Depression Centers Task Group on ECT set out to define best practices for harmonizing the clinical documentation of ECT across treatment centers to promote clinical interoperability and facilitate a nationwide collaboration that would enable multisite quality improvement and longitudinal research in real-world settings. This article reports on the work of this effort. It focuses on the use of ECT for major depressive disorder, which accounts for the majority of ECT referrals in most countries. However, most of the recommendations on clinical documentation proposed herein will be applicable to the use of ECT for any of its indications.

Ketamine Infusions Administered Solely by Psychiatric Staff

Even though intravenous ketamine is not an FDA-approved depression treatment, multiple studies have shown a robust antidepressant effect which has led to an increase in clinical practices implementing its use to manage treatment-resistant depression. Traditionally, this therapy has been provided in both outpatient and inpatient settings, with anesthesia specialists and psychiatrists working collaboratively on most cases. Several studies have been conducted in various psychiatric settings to study the effects of ketamine in depression, mostly in a collaborative manner. Thorough search of the literature found no published reports on the use of ketamine infusions merely for clinical purposes in a psychiatric hospital setting, implemented solely by a psychiatric-based team without collaboration from anesthesia specialists. In an effort to explore the utilization of ketamine infusions, the Missouri University Psychiatric Center (MUPC), an acute mental inpatient facility, formed a ketamine infusion team composed solely of mental health clinicians and staff to investigate the use of ketamine infusions by a psychiatric team. To our knowledge, this is the first-time ketamine infusions have been administered by a clinically based psychiatric team in a psychiatric hospital. The MUPC ketamine team has proved that ketamine infusions may provide a unique intervention safely and efficaciously without the need for collaboration with other medical specialties since initiating this pilot program.

The Use of Electroconvulsive Therapy in Neuropsychiatric Complications of Coronavirus Disease 2019: A Systematic Literature Review and Case Report

BACKGROUND

There is a significant prevalence of new onset neuropsychiatric symptoms (NPS), some severe and persistent, in patients with coronavirus disease 2019 (COVID-19).

OBJECTIVE

This study reports on the use of electroconvulsive therapy (ECT) to treat NPS associated with COVID-19.

METHODS

A review of the literature pertaining to the use of ECT in patients with COVID-19 and NPS was performed through PubMed, PsycINFO, and MEDLINE. Search terms included "Electroconvulsive Therapy" and "ECT," combined with "COVID-19" and "Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2)." In addition, we present a case in which ECT was used to achieve complete remission in a patient who developed new onset, treatment-resistant depression, psychosis, and catatonia, associated with COVID-19.

RESULTS

A total of 67 articles were reviewed with 3 selected for inclusion. These articles detailed 3 case reports of patients with new onset NPS (mania, psychosis and suicidality, and catatonia) that developed in the context of active COVID-19 and were treated successfully with ECT.

CONCLUSIONS

ECT, a broad-spectrum treatment that has been found to be effective in various NPS (independent of etiology), is shown in our case report and others, to be safe and effective for NPS associated with COVID-19. Although we identified only 3 other cases in the literature, we believe that the probable antiinflammatory mechanism of ECT, its safety and tolerability, and the faster time to symptom remission support the need for more research and increased clinician awareness about this life-saving procedure.

[Pharmacology of ketamine and esketamine as rapid-acting antidepressants]

The lack of utter efficacy and fast action of commonly used antidepressants that selectively target the monoaminergic neurotransmission has led to the exploration of ketamine's actions. Ketamine's antidepressant effect was firstly described in 1973 and nowadays its therapeutic value as a fast- and long- lasting antidepressant has been extensively established. Ketamine is an antagonist of the N-Methyl-D-aspartate receptor (NMDAR) and its main mechanism of action via NMDAR inhibition expressed in GABAergic (gamma-Aminobutyric acid, GABA) interneurons may be relayed to its antidepressant effects. This review aims to describe the pharmacokinetic and pharmacodynamic profile of ketamine when used for treatment-resistant depression. Moreover, ketamine is a racemic mixture consisting of two enantiomers, R- and S- ketamine. We describe the pharmacology of esketamine, along with the guidelines for effective and safe intranasal administration of esketamine. Lastly, this review presents sex differences in preclinical and clinical studies of ketamine and esketamine administration.

Interleukin-8 and lower severity of depression in females, but not males, with treatment-resistant depression

INTRODUCTION

In cross-sectional studies of depressed patients, relationships between depression and levels of IL-8 are inconsistent, and have not been examined in relation to sex. Given identified sex differences in longitudinal data, it is important to evaluate sex-specific cross-sectional relationships between IL-8 and depressive symptoms, which may explain some inconsistency in the extant literature. It is further unknown whether IL-8 levels may relate to specific symptom profiles among depressed patients, with or without regard to sex.

METHODS

Among 108 patients with treatment resistant depression (50 females), we evaluated cross-sectional relationships between IL-8 and depression severity, as measured by the Hamilton Depression Rating Scale [HAM-D] Score, and examined sex-specific relationships, as well as relationships with depressive symptom profiles. Other inflammatory markers (IL-6, IL-10, TNF-α, CRP) were also explored in relation to HAM-D.

RESULTS

Higher IL-8 was associated with lower total HAM-D score (standardized β = -0.19, p = 0.049). Sex-specific effects were identified (IL-8 x sex interaction: p = 0.03), in which higher IL-8 related to lower HAM-D score in females (standardized β = -0.41, p = 0.004, effect size (sr2) = 0.17), but not males (standardized β = 0.02, p = 0.91). Among a subset of 94 patients (41 females) who had individual HAM-D items available, we evaluated relationships between IL-8 and HAM-D factor subscores. Across sexes, higher IL-8 was associated with lower anxiety/hypochondriasis subscores (standardized β = -0.31, p = 0.002; sex interaction: p = 0.99). Sex differences were identified for relationships between IL-8 and two other HAM-D factor subscores.

CONCLUSIONS

IL-8 may be related to anxiety symptoms across sexes, but may have a sex-specific relationship with other depressive symptoms. Further evaluation of sex-specific relationships between IL-8, depression symptom profiles, treatment response, and potential neurobiological correlates, may inform mechanisms of depression pathophysiology and aid in development of precision medicine strategies.

Using a machine learning approach to investigate factors associated with treatment-resistant depression among adults with chronic non-cancer pain conditions and major depressive disorder

OBJECTIVE

Presence of chronic non-cancer pain conditions (CNPC) among adults with major depressive disorder (MDD) may reduce benefits of antidepressant therapy, thereby increasing the possibility of treatment resistance. This study sought to investigate factors associated with treatment-resistant depression (TRD) among adults with MDD and CNPC using machine learning approaches.

METHODS

This retrospective cohort study was conducted using a US claims database which included adults with newly diagnosed MDD and CNPC (January 2007-June 2017). TRD was identified using a clinical staging algorithm for claims data. Random forest (RF), a machine learning method, and logistic regression was used to identify factors associated with TRD. Initial model development included 42 known and/or probable factors that may be associated with TRD. The final refined model included 20 factors.

RESULTS

Included in the sample were 23,645 patients (73% female mean age: 55 years; 78% with ≥2 CNPC, and 91% with joint pain/arthritis). Overall, 11.4% adults (N = 2684) met selected criteria for TRD. The five leading factors associated with TRD were the following: mental health specialist visits, polypharmacy (≥5 medications), psychotherapy use, anxiety, and age. Cross-validated logistic regression model indicated that those with TRD were younger, more likely to have anxiety, mental health specialist visits, polypharmacy, and psychotherapy use with adjusted odds ratios (AORs) ranging from 1.93 to 1.27 (all ps < .001).

CONCLUSION

Machine learning identified several factors that warrant further investigation and may serve as potential targets for clinical intervention to improve treatment outcomes in patients with TRD and CNPC.

[Ketamine self-medication in a patient with autism spectrum disorder and comorbid treatment-resistant depression]

We saw a 60-year-old male veterinarian with a history of autism spectrum disorder, major depressive disorder, and suicidality. He had been treated with more than 15 psychotropic medications, was admitted to inpatient care several times, and attempted suicide once. His current complaints included a decline in social functioning, repetitive behaviour, sensory hypersensitivity, anxiety, low mood, anhedonia, lack of energy, and chronic suicidality. His last medication consisted of risperidone and valproic acid. Despite intensive treatment, he remained impaired by his complaints and could not return to work. After self-medication with ketamine, he reported that his depressive and suicidal complaints disappeared and that his autism-related complaints diminished. This case - together with previous clinical research - suggests that ketamine is likely to be effective against depression and suicidality, that ketamine is potentially effective against autism-related symptoms, and that increasing awareness of the beneficial effects of ketamine can lead to unsupervised, and therefore risky, use of ketamine as a form of self-medication.

[Pramipexole in bipolar depression: a literature review and clinical recommendations]

BACKGROUND

Bipolar depression is a common clinical problem and forms a major challenge in clinical practice as there is a paucity of treatment options.

AIM

To review the evidence for pramipexole as a treatment option in treatment-resistant bipolar depression.

METHOD

A PubMed search was performed using the search terms bipolar disorder or mood disorder or depressive disorder, treatment resistant and pramipexole or dopamine agonist.  There were no limits on publication year.  Furthermore, we contacted authors of included articles to help develop clinical recommendations for the use of pramipexole in bipolar depression.

RESULTS

Our results consist of 4 meta-analyses which are also systematic reviews. 2 RCTs, 1 open label trial, 2 naturalistic studies; 2 retrospective studies. The first RCT showed a significantly higher response compared to placebo (67% vs 20%), but not for remission (20% vs. 16%). A second RCT reported higher response and remission results with pramipexole compared to placebo (60% vs. 9%, 40% vs. 9%). Pramipexole was generally well tolerated.

CONCLUSION

The use of pramipexole in treatment resistant bipolar depression appears promising, but remains understudied. There is a need for randomized controlled trials.

Subgenual cingulate connectivity and hippocampal activation are related to MST therapeutic and adverse effects

Aberrant connectivity between the dorsolateral prefrontal cortex (DLPFC) and the subgenual cingulate cortex (SGC) has been linked to the pathophysiology of depression. Indirect evidence also links hippocampal activation to the cognitive side effects of seizure treatments. Magnetic seizure therapy (MST) is a novel treatment for patients with treatment resistant depression (TRD). Here we combine transcranial magnetic stimulation with electroencephalography (TMS-EEG) to evaluate the effects of MST on connectivity and activation between the DLPFC, the SGC and hippocampus (Hipp) in patients with TRD. The TMS-EEG was collected from 31 TRD patients prior to and after an MST treatment trial. Through TMS-EEG methodology we evaluated significant current scattering (SCS) as an index of effective connectivity between the SGC and left DLPFC. Significant current density (SCD) was used to assess activity at the level of the Hipp. The SCS between the SGC and DLPFC was reduced after the course of MST (p < 0.036). The DLPFC-SGC effective connectivity reduction correlated with the changes in Hamilton depression score pre-to-post treatment (R = 0.46; p < 0.031). The SCD localized to the Hipp was reduced after the course of MST (p < 0.015), and the SCD change was correlated with montreal cognitive assessment (MOCA) scores pre-post the course of MST (R = -0.59; p < 0.026). Our findings suggest that MST treatment is associated with SGC-DLPFC connectivity reduction and that changes to cognition are associated with Hipp activation reduction. These findings demonstrate two distinct processes which drive efficacy and side effects separately, and might eventually aid in delineating physiological TRD targets in clinical settings.

The identification, assessment and management of difficult-to-treat depression: An international consensus statement

BACKGROUND

Many depressed patients are not able to achieve or sustain symptom remission despite serial treatment trials - often termed "treatment resistant depression". A broader, perhaps more empathic concept of "difficult-to-treat depression" (DTD) was considered.

METHODS

A consensus group discussed the definition, clinical recognition, assessment and management implications of the DTD heuristic.

RESULTS

The group proposed that DTD be defined as "depression that continues to cause significant burden despite usual treatment efforts". All depression management should include a thorough initial assessment. When DTD is recognized, a regular reassessment that employs a multi-dimensional framework to identify addressable barriers to successful treatment (including patient-, illness- and treatment-related factors) is advised, along with specific recommendations for addressing these factors. The emphasis of treatment, in the first instance, shifts from a goal of remission to optimal symptom control, daily psychosocial functional and quality of life, based on a patient-centred approach with shared decision-making to enhance the timely consideration of all treatment options (including pharmacotherapy, psychotherapy, neurostimulation, etc.) to optimize outcomes when sustained remission is elusive.

LIMITATIONS

The recommended definition and management of DTD is based largely on expert consensus. While DTD would seem to have clinical utility, its specificity and objectivity may be insufficient to define clinical populations for regulatory trial purposes, though DTD could define populations for service provision or phase 4 trials.

CONCLUSIONS

DTD provides a clinically useful conceptualization that implies a search for and remediation of specific patient-, illness- and treatment obstacles to optimizing outcomes of relevance to patients.

[Investigation of the acute effect of bilateral repetitive transcranial magnetic stimulation (rTMS) in therapy resistant major depression patients]

INTRODUCTION

There is a 20-year history of rTMS treatment, however, is not available in Hungary in routine clinical practice for therapy resistant depression (TRD). In this study we analysed the change of symptom profile of a Hungarian cohort with TRD using bilateral rTMS treatment.

METHODS

A cohort of 22 patients suffering from TRD was enrolled in the study. For assessment of the phenotypic profile the Beck Depression Inventory (BDI), The Beck Anxiety Inventory (BAI), The Montgomery-Asberg Depression Rating Scale (MADRS), the Snaith-Hamilton Pleasure Scale (SHAPS), the Insomnia Severity Index (ISI), and the Trail Making Test were applied. Differences of mean scores of scales were compared between the day 1 (before treatment) and the day 14 (after conclusion of treatment). Furthermore, we performed phenotypic comparisons between the gender subgroups.

RESULTS

In the total sample significant reduction of symptom scores was found on the depression (pMADRS=0,022; pBDI=0,001) and the anxiety scales (pBAI=0,020) and in case of the TMT-A test (pTMT-A=0,019) at the end of the treatment. The mean scores of the SHAPS, the ISI and the TMT-B did not change up to the day 14. In the sex-specific analysis we found that in men only sleep disorder was improved (p=0,015), while in women both depression scores and TMT-A score decreased significantly (MADRSp=0,015; BDIp=0,005; TMT-Ap=0,036). There were no adverse events during the rTMS treatment.

CONCLUSION

2x5 sessions of bilateral rTMS treatment is an effective, safety applicable intervention in patients with TRD. Our results suggest that significant improvement of depressive, anxious and attention symptoms can be observed already after 10th session. Our findings highlighted that different symptoms evolve in women and men due to the acute effect of the rTMS treatment. Further follow-up study is required to evaluate the long-term effect of rTMS concerning the maintenance of symptom reduction and potential change of anhedonia and insomnia.

Animal models of major depression: drawbacks and challenges

Major depression is a leading contributor to the global burden of disease. This situation is mainly related to the chronicity and/or recurrence of the disorder, and to poor response to antidepressant therapy. Progress in this area requires valid animal models. Current models are based either on manipulating the environment to which rodents are exposed (during the developmental period or adulthood) or biological underpinnings (i.e. gene deletion or overexpression of candidate genes, targeted lesions of brain areas, optogenetic control of specific neuronal populations, etc.). These manipulations can alter specific behavioural and biological outcomes that can be related to different symptomatic and pathophysiological dimensions of major depression. However, animal models of major depression display substantial shortcomings that contribute to the lack of innovative pharmacological approaches in recent decades and which hamper our capabilities to investigate treatment-resistant depression. Here, we discuss the validity of these models, review putative models of treatment-resistant depression, major depression subtypes and recurrent depression. Furthermore, we identify future challenges regarding new paradigms such as those proposing dimensional rather than categorical approaches to depression.

[The care standard 'Depressive disorders']

The care standard 'Depressive disorders' describes the complete patient journey for patients with depressive symptoms and disorders from the age of 8 years onwards.<br/> AIM: To describe the most important recommendations in this care standard.<br/> METHOD: The care standard is an adaptation of the existing guidelines for depression, supplemented with practical knowledge from professionals and patients' values and preferences.<br/> RESULTS: Core elements in the care for depression are an appropriate use of care and a focus on relapse prevention. A combination of psychotherapy and medication is indicated for persistent depression and more sessions of psychotherapy might be required. There is some evidence for the use of repetitive transcranial magnetic stimulation in treatment-resistant depression.<br/> CONCLUSION: The care standard is an important instrument to improve the quality of care for depression at both the organisational and the regional level.

Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study

OBJECTIVES

To identify patterns in euthanasia requests and practices relating to psychiatric patients; to generate recommendations for future research.

DESIGN

Retrospective analysis of data obtained through medical file review.

SETTING

Outpatient psychiatric clinical setting in the Dutch-speaking region of Belgium, between October 2007 and December 2011; follow-up at the end of December 2012.

PARTICIPANTS

100 consecutive psychiatric patients requesting euthanasia based on psychological suffering associated with psychiatric disorders (77 women, 23 men; mean age 47 years; age range 21-80 years).

MAIN OUTCOME MEASURES

Patient sociodemographic characteristics; diagnoses; decisions on euthanasia requests; circumstances of euthanasia procedures; patient outcomes at follow-up.

RESULTS

Most patients had been referred for psychiatric counselling by their physician (n=55) or by LEIF (Life End Information Forum) (n=36). 90 patients had >1 disorder; the most frequent diagnoses were depression (n=58) and personality disorder (n=50). 38 patients required further testing and/or treatment, including 13 specifically tested for autism spectrum disorder (ASD); 12 received an ASD diagnosis (all Asperger syndrome). In total, 48 of the euthanasia requests were accepted and 35 were carried out. Of the 13 remaining patients whose requests were accepted, 8 postponed or cancelled the procedure, because simply having this option gave them enough peace of mind to continue living. In December 2012, 43 patients had died, including 35 by euthanasia; others died by suicide (6), palliative sedation (1) and anorexia nervosa (1).

CONCLUSIONS

Depression and personality disorders are the most common diagnoses in psychiatric patients requesting euthanasia, with Asperger syndrome representing a neglected disease burden. Further research is needed, especially prospective quantitative and qualitative studies, to obtain a better understanding of patients with psychiatric disorders who request euthanasia due to unbearable psychological suffering.

Possible involvement of rumination in gray matter abnormalities in persistent symptoms of major depression: an exploratory magnetic resonance imaging voxel-based morphometry study

BACKGROUND

A recent meta-analysis of many magnetic resonance imaging (MRI) studies has identified brain regions with gray matter (GM) abnormalities in patients with major depressive disorder (MDD). A few studies addressing GM abnormalities in patients with treatment-resistant depression (TRD) have yielded inconsistent results. Moreover, although TRD patients tend to exhibit ruminative thoughts, it remains unclear whether rumination is related to GM abnormalities in such patients or not.

METHODS

We conducted structural MRI scans and voxel-based morphometry (VBM) to identify GM differences among 29 TRD patients and 29 healthy age-matched and sex-matched controls. A response style questionnaire was used to assess the respective degrees of rumination in TRD patients. Structural correlates of rumination were examined.

RESULTS

TRD patients showed several regions with smaller GM volume than in healthy subjects: the left dorsal anterior cingulate cortex (ACC), right ventral ACC, right superior frontal gyrus, right cerebellum (Crus I), and cerebellar vermis. GM volumes in these regions did not correlate to rumination. However, whole-brain analysis revealed that rumination was positively correlated with the GM volume in the right superior temporal gyrus in TRD patients.

LIMITATIONS

Structural correlates of rumination were examined only in TRD patients.

CONCLUSIONS

Our data provide additional evidence supporting the hypothesis that TRD patients show GM abnormalities compared with healthy subjects. Furthermore, this report is the first to describe a study identifying brain regions for which the GM volume is correlated with rumination in TRD patients. These results improve our understanding of the anatomical characteristics of TRD.

Impaired prefronto-thalamic functional connectivity as a key feature of treatment-resistant depression: a combined MEG, PET and rTMS study

Prefrontal left-right functional imbalance and disrupted prefronto-thalamic circuitry are plausible mechanisms for treatment-resistant depression (TRD). Add-on repetitive transcranial magnetic stimulation (rTMS), effective in treating antidepressant-refractory TRD, was administered to verify the core mechanisms underlying the refractoriness to antidepressants. Thirty TRD patients received a 2-week course of 10-Hz rTMS to the left dorsolateral prefrontal cortex (DLPFC). Depression scores were evaluated at baseline (W0), and the ends of weeks 1, 2, and 14 (W14). Responders were defined as those who showed an objective improvement in depression scores ≥50% after rTMS. Left-right frontal alpha asymmetry (FAA) was measured by magnetoencephalography at each time point as a proxy for left-right functional imbalance. Prefronto-thalamic connections at W0 and W14 were assessed by studying couplings between prefrontal alpha waves and thalamic glucose metabolism (PWTMC, reflecting intact thalamo-prefrontal connectivity). A group of healthy control subjects received magnetoencephalography at W0 (N = 50) to study whether FAA could have a diagnostic value for TRD, or received both magnetoencephalography and positron-emission-tomography at W0 (N = 10) to confirm the existence of PWTMC in the depression-free state. We found that FAA changes cannot differentiate between TRD and healthy subjects or between responders and non-responders. No PWTMC were found in the TRD group at W0, whereas restitution of the PWTMC was demonstrated only in the sustained responders at W14 and euthymic healthy controls. In conclusion, we affirmed impaired prefronto-thalamic functional connections, but not frontal functional imbalance, as a core deficit in TRD.