The impact of treatment resistance on outcome and course of electroconvulsive therapy in major depressive disorder.

INTRODUCTION: Major depressive disorder (MDD) is a common psychiatric disorder. Despite several treatment options, a subgroup of patients will not respond to the commonly used antidepressant treatments and thus express treatment resistance (TRD). TRD can be quantified with the Dutch Measure for Treatment Resistance in Depression (DM-TRD). Electroconvulsive therapy (ECT) is an effective treatment for MDD, also in TRD. Yet, the position of ECT as "treatment-of-last-resort" may decrease the likelihood of beneficial outcome. Our aim was to investigate the association between treatment resistance and outcome and course of ECT. METHODS: We performed a retrospective, multicenter cohort study with 440 patients of which data was retrieved from patient records as collected in the Dutch ECT Cohort database. Linear and logistic regression models were used to explore the association between level of treatment resistance and outcome of ECT. Median split was used to explore the differences between high and low level of TRD and course of treatment. RESULTS: A higher DM-TRD score was associated with significantly smaller reduction of depression symptoms (R2 = 0.160; ß = -2.968; p < 0.001) and lower chance of response (OR = 0.821 [95 CI: 0.760-0.888]; ß = -0.197; p < 0.001). Low level TRD patients underwent fewer ECT sessions (mean 13 ± 6 SD vs. 16 ± 7 SD; p < 0.001) and fewer switches from right unilateral tot bifrontotemporal electrode placement (29% vs. 40%; p = 0.032). CONCLUSION: Reserving ECT as "treatment-of-last-resort" in the treatment algorithm for MDD seems questionable, because in our study lower level of treatment resistance predicted more beneficial ECT-outcome. Moreover, providing ECT in less treatment resistant patients showed fewer needed ECT-sessions and less switches to BL electrode placement, which may decrease the risk for cognitive side-effects.

Systematic review and meta-analysis of psychological interventions in people with diabetes and elevated diabetes-distress.

AIMS: The clinical relevance of diabetes-distress is increasingly recognized, but little is known about the efficacy of interventions specifically targeted to treat elevated diabetes-distress. Therefore, this systematic review sought to determine the efficacy of psychological interventions aimed at treating elevated diabetes-distress in people with Type 1 or Type 2 diabetes. METHODS: We systematically searched literature from five databases. Randomized controlled trials (RCTs) with an English abstract, describing the results of a psychological intervention in adults with diabetes were included. Articles were eligible for inclusion if the primary outcome was diabetes-distress measured by the Problem Areas in Diabetes Scale (PAID-5/PAID-20) or the Diabetes Distress Scale (DDS-17). Only mean group diabetes-distress values above cut-off at baseline or the results of a subgroup above cut-off (PAID-5 ≥ 8, PAID-20 ≥ 40 or DDS-17 ≥ 3) were included. RESULTS: The search yielded 8907 articles. After removing 2800 duplicates, 6107 articles remained. Titles and abstracts were screened, leaving 394 potential articles of interest, nine of which were RCTs. In a random-effects meta-analysis, the pooled effect size for diabetes-distress was 0.48 (Cohen's d), Z = 3.91, P < 0.0001. Statistical heterogeneity was I² = 46.67% (confidence intervals 45.06% to 48.28%). Diabetes-tailored psychological interventions reduced HbA1c (Cohen's d = 0.57), whereas mindfulness-based interventions did not (Cohen's d = 0.11). CONCLUSIONS: This systematic review shows that specifically diabetes-tailored psychological interventions are effective in reducing elevated diabetes-distress and HbA1c . More rigorous studies are warranted to establish the full potential of these interventions. PROSPERO database registration ID: CRD42017075290.

Acceptance of guidance to care at the emergency department following attempted suicide.

BACKGROUND: Research, aimed at improving the continuity of care after hospital discharge following attempted suicide focuses on the effectiveness of the interventions. Little attention has been paid to patients who immediately decline guidance to advised post-discharge care. We aimed to identify differences between accepters and decliners of guidance to care (GtC) in relation to the characteristics of patients who presented at the emergency department (ED) of an urban hospital in the Netherlands after attempted suicide. METHOD: This cross-sectional study included all patients who presented at the ED of OLVG-West Amsterdam with a suicide attempt or intentional self-harm and were referred for psychiatric evaluation. Data were collected over a period of twenty months using a semi-structured questionnaire. Subgroups were described in relation the acceptance of GtC using univariate and multivariate logistic regression analyses. RESULTS: In total, 257 patients were included. GtC was accepted by 77%. Suicide attempters who reported loneliness as reason for the attempt showed a positive relation to acceptance. No indication was found that patients at higher risk for suicide are more reluctant to accept GtC. Suicide attempters with a non-Western ethnicity, especially patients with a Turkish/Moroccan ethnicity, declined contact by the GtC nurse significantly more often. In addition, patients who currently did not receive care were significantly more often of non-Western ethnicity and younger than 25. CONCLUSION: Acceptance of GtC is high among patients who presented at the ED after attempted suicide. The patients who were the most reluctant to accept GtC were young suicide attempters of non-Western ethnicity who were not in current care. As this study is the first to address the acceptance of GtC, we point out two lines of inquiry for further research. First, reasons to accept or decline need to be investigated further since only interventions that are accepted by patients have a chance to improve clinically relevant outcome. Second, follow-up research is warranted comparing the adherence to advised post-discharge care and attempted or completed suicide among accepters versus decliners of GtC in various ethnic and sociodemographic subgroups.

Myelopathy in systemic lupus erythematosus: a case report and a review of the literature.

Myelopathy, a severe condition characterised by paraparesis, sensory deficits and sphincter dysfunction, is one of the neuropsychiatric manifestations that have been described in patients with systemic lupus erythematosus (SLE). SLE-associated myelopathy may confront clinicians with a challenging decision-making process due to the broad differential diagnosis, the lack of disease-specific findings, and the urgency to initiate immunosuppressive therapy early in the course of the disease to favourably affect outcome.

The assessment of publication pressure in medical science; validity and reliability of a Publication Pressure Questionnaire (PPQ).

PURPOSE: To determine content validity, structural validity, construct validity and reliability of an internet-based questionnaire designed for assessment of publication pressure experienced by medical scientists. METHODS: The Publication Pressure Questionnaire (PPQ) was designed to assess psychological pressure to publish scientific papers. Content validity was evaluated by collecting independent comments from external experts (n = 7) on the construct, comprehensiveness and relevance of the PPQ. Structural validity was assessed by factor analysis and item response theory (IRT) using the generalized partial credit model. Pearson's correlation coefficients were calculated to assess potential correlations with the emotional exhaustion and depersonalization subscales of the Maslach Burnout Inventory (MBI). Single test reliability (lambda2) was obtained from the IRT analysis. RESULTS: Content validity was satisfactory. Confirmatory factor analysis did not support the presence of three initially assumed separate domains of publication pressure (i.e., personally experienced publication pressure, publication pressure in general, pressure on position of scientist). After exclusion of the third domain (six items), we performed exploratory factor analysis and IRT. The goodness-of-fit statistics for the IRT assuming a single dimension were satisfactory when four items were removed, resulting in 14 items of the final PPQ. Correlations with the emotional exhaustion and depersonalization scales of the MBI were 0.34 and 0.31, respectively, supporting construct validity. Single test administration reliability lambda2 was 0.69 and 0.90 on the test scores and expected a posteriori scores, respectively. CONCLUSION: The PPQ seems a valid and reliable instrument to measure publication pressure among medical scientists.

[Gamma-hydroxybutyric acid (GHB) dependence and the GHB withdrawal syndrome: diagnosis and treatment]. / GHB-afhankelijkheid en -onthoudingssyndroom: diagnostiek en behandeling.

Gamma-hydroxybutyric acid (GHB) is a neurotransmitter that occurs naturally in the brain and is increasingly being used as a 'party drug' because of its relaxing and euphoria-inducing effects. GHB has a limited medical use in the treatment of narcolepsy. GHB-intoxications occur often in non-medical use, and generally result in a coma of short duration. GHB use several times a day can lead to tolerance and dependence. After sudden cessation or reduction of intensive GHB use, a severe withdrawal syndrome may occur with symptoms varying from tremor, anxiety and agitation to autonomic instability, hallucinations and delirium. Treatment of the GHB withdrawal syndrome consists of supportive care and benzodiazepines, often in high doses. The controlled detoxification of GHB using pharmaceutical GHB in an adjusted dose is currently being investigated in the Netherlands. There is no literature concerning the treatment of patients following GHB intoxication or after detoxification.

[Effects of bariatric surgery not affected by psychiatric comorbidity: a systematic review of studies of morbidly obese patients]. / Psychiatrische stoornis beïnvloedt het effect van bariatrische chirurgie niet: een systematische review van onderzoek bij morbide obese patiënten.

OBJECTIVE: To review the literature on the predictive value of psychiatric comorbidity for weight loss following bariatric surgery in patients with morbid obesity. DESIGN: Systematic review. METHOD: PubMed databases were searched for literature comparing weight loss following bariatric surgery in morbidly obese patients with and without preoperative psychiatric symptoms. General psychiatric disorders were distinguished from eating disorders. RESULTS: The search yielded 204 references, 6 of which complied with inclusion criteria. 2 studies were retrospective (169 patients in total; the other 4 were prospective (1140 patients in total). The average follow-up period varied between 12 and 60 months. In 2 studies (n = 528 patients), the influence of eating disorders on the outcome of bariatric surgery was specifically studied. The quality of the studies was low. Psychiatric disorders and eating disorders did not influence the outcome of bariatric surgery. In 1 study, weight loss was less after surgery in patients diagnosed with more than 2 psychiatric disorders. CONCLUSION: In 5 of the 6 studies, psychiatric comorbidity was not related to the weight loss following bariatric surgery. In view of the differences in design and the poor quality of the studies, definite conclusions cannot be drawn. There is no indication that routine psychiatric screening should form part of the work-up for bariatric surgery. We advise that note should be taken of the psychiatric history and any current psychiatric treatment.

Efficacy and safety of two treatment algorithms in bipolar depression consisting of a combination of lithium, lamotrigine or placebo and paroxetine.

OBJECTIVE: In a previous paper, we reported about the efficacy of the addition of lamotrigine to lithium in patients with bipolar depression. In the second phase of this study paroxetine was added to ongoing treatment in non-responders. METHOD: Bipolar depressed patients (n = 124) treated with lithium were randomized to addition of lamotrigine or placebo. In non-responders after 8 weeks, paroxetine 20 mg was added for another 8 weeks to ongoing treatment. RESULTS: After 8 weeks the improvement in patients treated with lamotrigine vs. patients treated with placebo was significant. After addition of paroxetine this difference disappeared as a result of greater further improvement in the non-responders to placebo. CONCLUSION: Addition of lamotrigine to lithium was found effective in bipolar depressed patients. Further addition of paroxetine in non-responders to lithium plus lamotrigine did not appear to provide additional benefit, while it appeared to do so in non-responders to lithium plus placebo.

[How can the results of primary-care treatment for depression be improved?]. / Hoe kunnen de resultaten van de eerstelijnsbehandeling van depressie worden verbeterd?

BACKGROUND: The results of treatment for depression are frequently disappointing. The main reasons for this are inadequate treatment and non-compliance. AIM: This article attempts to deal with the question of how patient compliance and the results of treatment for depression can be improved. METHOD: We performed a critical analysis of the literature. We searched Medline (1966- January 2002), psycinfo (1984-January 2002), Embase (1980-January 20002) and the Cochrane Controlled Trials Register (1966-Janaury 2002) for reports of randomised controlled trials. In our search we used the terms 'patient compliance', 'adherence', patient dropout', 'depression', 'depressive disorder', and 'affective disorder'. On the basis of the results of our search we compared two interventions that could be applied in Dutch practices. results We found 11 articles, all relating to treatment in primary care settings. Usual care proved to be inadequate. The quality of the usual care currently provided can be improved by extra interventions. So far there are no indications that complex interventions benefit the patient more than simple interventions, such as regular follow-up procedures. Therefore, for the time being, simple interventions are to be preferred. CONCLUSION: Treatment for depression can be improved by means of relatively simple interventions.

['Awakening': a confusing improvement during treatment with atypical antipsychotic agents]. / 'Awakening': een verwarrende verbetering tijdens behandeling met atypische antipsychotica.

Two schizophrenic women, aged 30 and 40 years, respectively, in whom the symptoms changed after a switch in medication from clozapine to aripiprazole and from olanzapine followed by quetiapine to risperidone, respectively, were initially thought to be experiencing a possible recurrence. After thoughtful consideration, the phenomena, such as disappearance of drowsiness and of loss of energy, in combination with cognitive improvement, could be understood as the result of a dramatic improvement, known as 'awakening'. This had significant consequences for the follow-up since the patients had to deal with new possibilities and emotions.

[Disorders of concentration and memory in young adults and middle-aged persons]. / Concentratie- en geheugenstoornissen op jongvolwassen en middelbare leeftijd.

Four patients, two women aged 29 and 52 and two men aged 46 and 25, respectively, consulted a neurologist for attention and memory disorders. Further investigation revealed that the symptoms were caused by metachromatic leucodystrophy, Graves' disease, Huntington's disease, and a psychological background, respectively. The first patient became dependent in 1.5 years, the second recovered after treatment, the third was independent with slowly progressive symptoms after 1 year, and the fourth was advised to consult a psychologist. Disorders of attention and memory in relatively young people deserve a detailed evaluation at the very first visit, involving the elaboration of an initially extensive differential diagnosis. Too early a separation between a psychic and an organic pathogenesis should be avoided. Indications for the presence of a neurological condition include: consultation at the initiative of others, a relatively brief duration of symptoms without a clear provoking factor, the absence of a psychiatric history or life event, cognitive dysfunction in several areas, abnormal behaviour and an incriminating family history.

Refill rate of antipsychotic drugs: an easy and inexpensive method to monitor patients' compliance by using computerised pharmacy data.

PURPOSE: In the literature, noncompliance to medication in patients with schizophrenia ranges from 20 to 89%. There is an urgent need for reliable and valid techniques that measure compliance in antipsychotic drug treatment. In this study, we use pharmacy-dispensing records to assess compliance by calculating the refill rate of antipsychotic medication. METHODS: Refill rates of chronic antipsychotic drug users in 1999 and in 2000 were established by dividing the number of prescribed days by the total number of calendar days that the patient was registered in a pharmacy prescription records database. RESULTS: More than 50% of patients using an antipsychotic drug show a refill rate that is associated with medication compliance (0.9-1.1). The number of daily antipsychotic drug intakes was associated with a divergent refill rate, more than once daily dosing was associated with a significantly elevated refill rate (p < 0.015). CONCLUSIONS: The refill rate is a valuable addition to the small arsenal of objective compliance measurement tools. It is an easy to obtain and inexpensive way to estimate (non)compliance. We recommend future studies to medication use in both mental and physical disorders, in order to further specify the actual value of refill rates in clinical practice.

[Delirium during withdrawal of venlafaxine]. / Delirium bij afbouw van venlafaxine.

A 35-year-old man with anxiety and depression who was treated with venlafaxine, 300 mg a day, developed severe withdrawal symptoms in the form of a delirium during gradual tapering of the dosage. The symptoms resolved when the dosage was kept constant and did not recur when the dosage was reduced more gradually. Withdrawal symptoms are common during discontinuation of antidepressants, particularly after prolonged use of agents with a short half-life. The symptoms are usually mild and transient, especially in the case of selective serotonin reuptake inhibitors and venlafaxine. The occurrence of delirium as a result of the withdrawal of venlafaxine has not been reported previously. Even when antidepressants are being withdrawn with care, one should remain alert to the possible development of severe withdrawal symptoms.

[Adverse effects after switching to a different generic form of paroxetine: paroxetine mesylate instead of paroxetine HCl hemihydrate]. / Bijwerkingen na overstappen op een ander generiek preparaat van paroxetine: paroxetine-mesilaat in plaats van paroxetine-HCl-hemihydraat.

Two patients, a 29-year-old man and a 32-year-old woman who were being treated with paroxetine HCl hemihydrate for depression and panic disorder with agoraphobia, respectively, unexpectedly developed complaints after switching to paroxetine mesylate. The symptoms were generalised itching with relapse of the depressive disorder in the man, and nausea with diarrhoea in the woman. The symptoms disappeared after the original treatment with paroxetine HCl hemihydrate was resumed. In the first patient, a rechallenge with the mesylate form of paroxetine led to the same complaints which subsided again after using the first product. Those treating such patients, and the patients themselves, should be informed if the delivery form of paroxetine is changed.

[Methods to improve patient compliance in the use of antidepressants]. / Methoden om de therapietrouw bij het gebruik van antidepressiva te verbeteren.

Compliance during treatment with antidepressants is important, yet about half of the patients stop using antidepressive medication within 3 months. A structured treatment programme, in which the patient actively participates, with extensive education, surveillance of side effects and compliance, simple regimes, improving problem-solving behaviour and eventually engaging and educating family members and friends can improve compliance. This has been demonstrated in published studies. Research has shown that interventions that enhance compliance can lead to a better outcome of the depression.