Pharmacological Strategies in the Prevention of Relapse After Electroconvulsive Therapy
ABSTRACT OBJECTIVE: To determine whether starting antidepressant medication at the start of electroconvulsive therapy (ECT) reduces post-ECT relapse and to determine whether continuation pharmacotherapy with nortriptyline (NT) and lithium (Li) differs in efficacy or adverse effects from continuation pharmacotherapy with venlafaxine (VEN) and Li. METHODS: During an acute ECT phase, 319 patients were randomized to treatment with moderate dosage bilateral ECT or high-dosage right unilateral ECT. They were also randomized to concurrent treatment with placebo, NT, or VEN. Of 181 patients to meet post-ECT remission criteria, 122 (67.4%) participated in a second continuation pharmacotherapy phase. Patients earlier randomized to NT or VEN continued on the antidepressant, whereas patients earlier randomized to placebo were now randomized to NT or VEN. Lithium was added for all patients who were followed until relapse or 6 months. RESULTS: Starting an antidepressant medication at the beginning of the ECT course did not affect the rate or timing of relapse relative to starting pharmacotherapy after ECT completion. The combination of NT and Li did not differ from VEN and Li in any relapse or adverse effect measure. Older age was strongly associated with lower relapse risk, whereas the type of ECT administered in the acute phase and medication resistance were not predictive. Across sites, 50% of the patients relapsed, 33.6% continued in remission 6 months after ECT, and 16.4% dropped out. CONCLUSIONS: Starting an antidepressant medication during ECT does not affect relapse, and there are concerns about administering Li during an acute ECT course. Nortriptyline and VEN were equally effective in prolonging remission, although relapse rates after ECT are substantial despite intensive pharmacology. As opposed to the usual abrupt cessation of ECT, the impact of an ECT taper should be evaluated.
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ABSTRACT: Despite a wide variety of therapeutic interventions for major depressive disorder (MDD), treatment resistant depression (TRD) remains to be prevalent and troublesome in clinical practice. In recent years, deep brain stimulation (DBS) has emerged as an alternative for individuals suffering from TRD not responding to combining antidepressants, multiple adjunctive strategies and electroconvulsive therapy (ECT). Although the best site for TRD-DBS is still unclear, pilot data suggests that the medial forebrain bundle (MFB) might be a key target to accomplish therapeutic efficacy in TRD patients. To explore the anatomic, electrophysiologic, neurocognitive and treatment data supporting the MFB as a target for TRD-DBS. The MFB connects multiple targets involved in motivated behavior, mood regulation and antidepressant response. Specific phenomenology associated with TRD can be linked specifically to the superolateral branch (sl) of the MFB (slMFB). TRD patients who received DBS-slMFB reported high response/remission rates with an improvement in functioning and no significant adverse outcomes in their physical health or neurocognitive performance. Discussion The slMFB is an essential component of a network of structural and functional pathways connecting different areas possibly involved in the pathogenesis of mood disorders. Therefore, the slMFB should be considered as an exciting therapeutic target for DBS therapy to achieve a sustained relief in TRD patients. There is an urgent need for clinical trials exploring DBS-slMFB in TRD. Further efforts should pursue measuring baseline pro-inflammatory cytokines, oxidative stress, and cognition as possible biomarkers of DBS-slMFB response in order to aid clinicians in better patient selection. Copyright © 2014 Elsevier Inc. All rights reserved.Progress in Neuro-Psychopharmacology and Biological Psychiatry 12/2014; 58. DOI:10.1016/j.pnpbp.2014.12.003 · 4.03 Impact Factor
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ABSTRACT: Objectives: The aim of this study was to determine whether current guidance or consensus regarding continuation pharmacotherapy after successful electroconvulsive therapy (ECT) was being followed by referring clinicians in West Sussex, United Kingdom. Methods: A complete audit cycle examining psychotropic medication after successful ECT for patients with severe depression was performed. Clinical and ECT records (electronic and paper) were reviewed, and relapse rates in the 4 commonly prescribed psychotropic medication groups were compared. Results: The pattern of relapse in the 4 groups was similar for both audits 1 and 2. Taking the 102 patients as a whole, the lowest relapse rates were recorded for patients taking a combination of an antidepressant and lithium (16% relapsed within 6 months of successful ECT). Patients taking a combination of antipsychotic and antidepressants fared the worst with 75% relapse rate. This was followed by those taking a combination of antidepressant and a mood stabilizer (other than lithium) (69%). Patients taking antidepressant(s) only were associated with a relapse rate of 60%. Audit 2 demonstrated that clinicians did not change their prescribing practices for their patients after successful ECT despite the efforts made in widely disseminating the results of audit 1. In particular, there was no increase in the use of lithium. Conclusions: Not all psychotropic medication prescribing for patients receiving ECT for depression followed available and current guidance or consensus. More needs to be done to understand the reasons for the reluctance to use lithium if relapse rates after ECT are to improve.Journal of Ect 07/2014; 31(1). DOI:10.1097/YCT.0000000000000164 · 1.39 Impact Factor
Article: Depression in the Elderly[Show abstract] [Hide abstract]
ABSTRACT: Key Clinical Points Care of the Asplenic Patient Late-life depression (occurring in persons 60 years of age or older) is common and is often associated with coexisting medical illness, cognitive dysfunction, or both. Depressed older adults are at increased risk for suicide. Asplenic patients in whom fever develops should receive empirical antimicrobial therapy immediately. Screening for depression is important, but positive screening results should be followed by a thorough evaluation to assess patient safety and ensure that treatment is warranted. Either pharmacotherapy or psychotherapy may be used as first-line therapy. Currently available antidepressants show efficacy in depressed older populations, but older adults may be at increased risk for medication side effects. Selective serotonin-reuptake inhibitors (SSRIs) are considered first-line pharmacotherapy. Standardized psychotherapy techniques are also effective for depression in older adults.New England Journal of Medicine 09/2014; 371(13):1228-1236. DOI:10.1056/NEJMcp1402180 · 54.42 Impact Factor