Sex-specifics of ECT outcome.

OBJECTIVE: Electroconvulsive therapy (ECT) is the most effective treatment for patients with severe major depressive disorder (MDD). Given the known sex differences in MDD, improved knowledge may provide more sex-specific recommendations in clinical guidelines and improve outcome. In the present study we examine sex differences in ECT outcome and its predictors. METHODS: Clinical data from 20 independent sites participating in the Global ECT-MRI Research Collaboration (GEMRIC) were obtained for analysis, totaling 500 patients with MDD (58.6 % women) with a mean age of 54.8 years. Severity of depression before and after ECT was assessed with validated depression scales. Remission was defined as a HAM-D score of 7 points or below after ECT. Variables associated with remission were selected based on literature (i.e. depression severity at baseline, age, duration of index episode, and presence of psychotic symptoms). RESULTS: Remission rates of ECT were independent of sex, 48.0 % in women and 45.7 % in men (X2(1) = 0.2, p = 0.70). In the logistic regression analyses, a shorter index duration was identified as a sex-specific predictor for ECT outcome in women (X2(1) = 7.05, p = 0.01). The corresponding predictive margins did show overlapping confidence intervals for men and women. CONCLUSION: The evidence provided by our study suggests that ECT as a biological treatment for MDD is equally effective in women and men. A shorter duration of index episode was an additional sex- specific predictor for remission in women. Future research should establish whether the confidence intervals for the corresponding predictive margins are overlapping, as we find, or not.

Renal concentrating ability and glomerular filtration rate in lithium-treated patients.

BACKGROUND: Lithium is the most effective drug for mood stabilization in bipolar disorder. However, lithium exposure has been associated with an impaired renal concentrating ability (RCA) and glomerular filtration rate (GFR). We examined RCA and estimated GFR in a cohort of patients treated with lithium. METHODS: 134 patients (≥ 18 years of age) with a mood disorder treated with lithium were screened; 100 patients were included. Demographic and clinical characteristics and blood and urine samples were collected. Additionally, a dDAVP-test was performed to determine maximal RCA. RESULTS: A dDAVP-test was performed in 98 patients (37 males, 61 females). Mean age was 51 years (SD: 12), median duration of lithium therapy 7 years (IQR: 4-15), mean maximal urine osmolality (Uosmol) 725 mOsmol/kg (SD: 153), and median eGFR 84 ml/min/1.73 m2 (IQR: 68-95). Fifty patients (51%) had an impaired RCA and 17 patients (17%) had nephrogenic diabetes insipidus (Uosmol 600-800 and < 600 mOsmol/kg, respectively). Notably, clinical symptoms did not predict an impaired RCA. Nineteen patients (19%) had an eGFR ≤ 60 ml/min/ 1.73 m2. Multivariable regression analysis showed a significant association between the duration of lithium treatment and maximal Uosmol (B = -6.1, 95%-CI: -9.4, -2.9, p < 0.001) and eGFR (B = -0.6, 95%-CI: 0.2, -3.3; p < 0.01). CONCLUSIONS: RCA is impaired in the majority of lithium-treated patients. Both RCA and eGFR are inversely associated with the duration of lithium therapy. Prospective follow-up will enable us to evaluate if abnormalities in RCA can be used to predict the development of lithium-induced chronic kidney disease.

[Renewing the curriculum for psychiatry]. / Het nieuwe opleidingsplan psychiatrie.

BACKGROUND: A new curriculum for psychiatric training will be developed by the Netherlands Psychiatric Association.
AIM: To describe the essential documents providing the framework for the curriculum.
METHOD: Essay providing background information on the essential documents.
RESULTS: The new curriculum has to prepare the residents for future practice in a changing value-based mental healthcare setting. Acquisition of general psychiatric competencies requires a curriculum with a broad common base, with special focus on psychiatry across the life-span, and only secondary differentiation. Cooperation with other medical and mental health professionals requires development of interpersonal leadership skills. Competencies will be evaluated using Entrusted Professional Activities (epa).
CONCLUSION: In line with the vision documents by the Dutch Association of Medical Specialists and Training Board, a new curriculum will be designed, envisaging a broadly-based curriculum, with secondary differentiation. Professionalism is the central competency.

Cardiovascular risk factors in outpatients with bipolar disorder.

BACKGROUND: The mortality due to cardiovascular diseases in bipolar patients is much higher than in the general population. It is unclear whether lithium treatment contributes to this cardiovascular morbidity. METHODS: The cardiovascular risk factors in outpatients with bipolar disorder on monotherapy lithium were explored. Cardiac (family) history, important habits and recent stressful events were assessed. Quetelet Index (QI) was calculated and blood samples were taken. Blood pressure (BP) was measured in supine position and during orthostatic challenge. RESULTS: 40 out of 81 patients on monotherapy lithium were studied in detail. In this group, one patient was hypothyroid; six patients suffered from hypertension. QI was > 25 in 57.5% of the patients; mean cholesterol level was 5.7 mmol/L. Renal functioning, electrolytes and glucose concentrations were normal. There were no significant relationships between the duration of lithium treatment, the duration of bipolar disorder, recent stressful events and hypertension. Out of the group of 81 patients on lithium monotherapy, 13 patients in total used antihypertensive medication, indicating a high prevalence of hypertension in this group as compared to the general population. CONCLUSIONS: Cardiovascular risk factors, including hypertension, were increased in a large proportion of this population on monotherapy lithium. However, no significant relationships were observed between duration of lithium treatment or bipolar disorder and presence of hypertension.