[Patient-related stressful experiences in psychiatry residency]. / Patiëntgerelateerde stresserende ervaringen tijdens de opleiding psychiatrie.

BACKGROUND: Residents in psychiatry can be confronted with patient-related stressful experiences which can be impactful. Guidelines for dealing with these are lacking. AIM: Questioning residents in psychiatry about patient-related stressful adversities, their impact and resources to contribute to the existing literature. METHOD: Qualitative study through semi-structured interviews of six psychiatry residents, followed by data-analysis using thematic analysis. RESULTS: Reported patient-related stressful experiences were suicide, verbal and imminent physical aggression, questioning expertise, concerns about legal consequences, powerlessness and expectations. Cognitive and physical impact was experienced with symptoms similar to acute stress disorder. The most important resource is social support. CONCLUSION: In this study new patient related stressful experiences are reported that have not previously been described in the literature. Since estimating the impact of a patient related stressful experience proves difficult, it seems appropriate that the environment of the resident offers active support and further development of residents’ skills is stimulated.

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.

[Rapid remission of psychotic symptoms with electro-convulsive therapy in treatment-resistant schizophrenia]. / Snelle remissie van psychotische symptomen met elektroconvulsietherapie bij therapieresistente schizofrenie.

Electroconvulsive therapy (ECT) has a reputation for rapid alleviation of symptoms, mainly in depressive disorders. In the current literature little attention has been paid to speed of response of psychotic symptoms in schizophrenia. We present the case of a 67-year old woman, diagnosed with schizophrenia and presenting with clozapine-resistant psychotic symptoms that swiftly remitted with ECT. We review the literature on rapid remission of schizophrenic psychosis during a treatment with ECT.

Evidence-based treatment strategies for rapid cycling bipolar disorder, a systematic review.

OBJECTIVES: Rapid cycling is a phase of bipolar disorder with increased episode frequencies. It is a severe and disabling condition that often poses a major challenge to the clinician. The aim of this paper is to give an overview of the evidence-based treatment options for rapid cycling. METHODS: A systematic search on Pubmed, Embase and Cochrane databases from inception until December 2021 was conducted according to the PRISMA guidelines. An additional search on clinicaltrials.gov was done. References of retrieved papers and key reviews were hand-searched. Randomized controlled trials including at least 10 patients with bipolar disorder, rapid cycling, reporting an objective outcome measure were selected. RESULTS: Our search, initially revealing 1330 articles, resulted in 16 papers about treatment of an acute mood episode, relapse prevention or both. Lithium, anticonvulsants, second generation antipsychotics, antidepressants and thyroid hormone were assessed as treatment options in the presented data. Evidence supporting the use of aripiprazole, olanzapine, quetiapine, valproate and lamotrigine for treatment of rapid cycling bipolar disorder was found. LIMITATIONS: Small sample sizes, different index episodes and variety of outcome measures. CONCLUSION: Evidence regarding treatment of rapid cycling remains scarce. Evidence supports the use of aripiprazole, olanzapine, and valproate for acute manic or mixed episodes, quetiapine for acute depressive episodes and aripiprazole and lamotrigine for relapse prevention. Given the paucity of available evidence, and the burden that accompanies rapid cycling, future research is warranted.

[Pramipexole in bipolar depression: a literature review and clinical recommendations]. / Pramipexol bij bipolaire depressie: een literatuurstudie en klinische aanbevelingen.

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.

[Electroconvulsive therapy in the treatment of depression in anorexia nervosa]. / Elektroconvulsietherapie in de behandeling van depressie bij anorexia nervosa.

BACKGROUND: Often anorexia nervosa occurs with other psychiatric comorbidities of which mood disorders are the most frequent. Depressive feelings hamper the chance of a favourable outcome of this persistent disorder. In addition, the underweight makes antidepressants work suboptimal. Electroconvulsive therapy (ECT) offers an important therapeutic value in the treatment of mood disorders. We are investigating whether ECT can be an effective treatment method for patients with anorexia nervosa and major depressive disorder. AIM: Analysis of the literature on the possible effectiveness of electroconvulsive therapy (ECT) in the treatment of major depressive disorder and anorexia nervosa supplemented with a case report. METHOD: Literature study in PubMed, Web of Science and Embase and a case report. RESULTS: 262 published articles were found between 1955 and 2020, 16 were found to be relevant. CONCLUSION: From the literature, clinical recommendations cannot be made binding. No randomized controlled trials have been published on this subject. However, we saw in our case study and in the literature found that clearing the depressive symptoms through electroconvulsive therapy led to an improvement in food and fluid intake. ECT has no effect on their deranged thought pattern.

[Farmacotherapeutic treatment of psychotic depression: a review]. / Farmacotherapeutische behandeling van psychotische depressie: een overzicht.

BACKGROUND: Psychotic depression is a severe disease with a lifetime prevalence between 0.35 and 1%. Several guidelines suggest electroconvulsion therapy (ECT) as first choice treatment, however, in practice a pharmacological approach is often used first. AIM: To offer an overview of scientific literature concerning the pharmacotherapeutic treatment of psychotic depression. METHOD: We searched 'Pubmed' for Dutch or English articles, published after 1999. RESULTS: The search strategy produced 26 articles, of which 6 were excluded because of a too small study population. In the references of used literature 4 more articles were witheld. 24 articles were included. Despite the severity of the disease and the high prevalence, the research regarding treatment of psychotic depression is limited. Besides ECT, we consider combination therapy with an antidepressant and an antipsychotic as the most supported treatment, for a duration of at least four months. After four months tapering off the antipsychotic can be considered. CONCLUSION: Based on the discussed research, it's difficult to arrive at conclusions regarding the choice of products. Olanzapine or quetiapine were investigated the most in combination with an SSRI. The combination of an SNRI (venlafaxine) and quetiapine shows good results. The distinct effect of treatment with a TCA calls for further investigation.

A longitudinal study of the association between basal ganglia volumes and psychomotor symptoms in subjects with late life depression undergoing ECT.

Psychomotor dysfunction (PMD) is a core element and key contributor to disability in late life depression (LLD), which responds well to electroconvulsive therapy (ECT). The neurobiology of PMD and its response to ECT are not well understood. We hypothesized that PMD in LLD is associated with lower striatal volume, and that striatal volume increase following ECT explains PMD improvement. We analyzed data from a two-center prospective cohort study of 110 LLD subjects (>55 years) receiving ECT. Brain MRI and assessment of mood, cognition, and PMD was performed 1 week before, 1 week after, and 6 months after ECT. Volumetry of the caudate nucleus, putamen, globus pallidus, and nucleus accumbens was derived from automatically segmented brain MRIs using Freesurfer®. Linear multiple regression analyses were used to study associations between basal ganglia volume and PMD. Brain MRI was available for 66 patients 1 week post ECT and in 22 patients also six months post ECT. Baseline PMD was associated with a smaller left caudate nucleus. One week after ECT, PMD improved and volume increases were detected bilaterally in the caudate nucleus and putamen, and in the right nucleus accumbens. Improved PMD after ECT did not relate to the significant volume increases in these structures, but was predicted by a nonsignificant volume change in the right globus pallidus. No volume differences were detected 6 months after ECT, compared to baseline. Although PMD is related to lower striatal volume in LLD, ECT-induced increase of striatal volume does not explain PMD improvement.

Understanding electroconvulsive therapy-related anxiety: a prospective study.

AIMS OF STUDY: Although electroconvulsive therapy (ECT)-related anxiety is experienced by a significant proportion of patients, it remains understudied. Our aim was to study the course of ECT-related anxiety during ECT. METHODS: Seventy-four patients with unipolar or bipolar depression, referred for ECT, were included. ECT-related anxiety was assessed the morning before each ECT session using the ECT-related Anxiety Questionnaire (ERAQ). RESULTS: Female patients reported more anxiety than men (F(1,64.6) = 3.95, P = 0.05). Patients with a psychotic depression were more anxious before the start of ECT (F(64.8) = 4.57, P = 0.04), but experienced a significant decrease in ECT-related anxiety (t(63.9) = -3.63, P = 0.0006), whereas patients with a non-psychotic depression remained stable on anxiety during their ECT course (t(63,9) = 0.76, P = 0.45). In addition, we found a significant correlation between the decrease of ECT-related anxiety and the decrease of depression-severity (r = 0.35; P = 0.04). CONCLUSION: There are individual differences in ECT-related anxiety trajectories during ECT. Both female patients and patients with psychotic depression experienced more ECT-related anxiety before the start of ECT. The severity of ECT-related anxiety decreased significantly in patients with a psychotic depression, but remained stable in patients without a psychotic depression during ECT. In addition, patients who showed a stronger decrease in depression-severity also showed a stronger decrease in ECT-related anxiety. A better understanding of ECT-related anxiety trajectories can help in designing anxiety-reducing interventions.

When to consider electroconvulsive therapy (ECT).

OBJECTIVE: To familiarize the reader with the role of electroconvulsive therapy (ECT) in current psychiatric medicine. METHOD: We review clinical indications for ECT, patient selection, contemporary ECT practice, maintenance treatment and ECT in major treatment guidelines. RESULTS: ECT is underutilized largely due to persisting stigma and lack of knowledge about modern ECT technique. CONCLUSION: ECT remains a vital treatment for patients with severe mood disorders, psychotic illness and catatonia.

Association between hippocampal volume change and change in memory following electroconvulsive therapy in late-life depression.

OBJECTIVE: Electroconvulsive therapy (ECT)-induced hippocampal volume change (HVC) has been repeatedly described in recent years. The similar time course of HVC and ECT-related cognitive effects suggest a relation, that is to date, understudied. This study investigates whether HVC following ECT predicts the change in memory performance six months after the end of the ECT treatment. METHODS: Hippocampal volume (HV) was measured via high-resolution 3D T1-weighted images in 88 patients with late-life depression, within 1 week before and after ECT. Memory performance was assessed before and six months after ECT. Multiple linear regression was used to examine whether change in memory performance could be predicted based on ECT-induced changes in HV. RESULTS: Larger right absolute HVC predicts less pronounced improvement on the VAT (visual memory) in the whole sample. For the 8-Word Test (verbal memory), Category Fluency Test (semantic memory), and MMSE, the effect is only present in patients who switched from right unilateral to bitemporal stimulation after six ECT sessions. Absolute HVC in the left hemisphere was not significantly related to cognitive change. CONCLUSION: A larger absolute change in right HV during ECT is associated with less improvement in memory performance up to 6 months post-ECT.

[Persistant underuse of ECT for persistant depressive disorder?] / Persisterend ondergebruik van ECT bij persisterende depressieve stoornis?

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Long-term neurocognitive functioning after electroconvulsive therapy in patients with late-life depression.

OBJECTIVE: There is ongoing concern about the possible negative impact of ECT on neurocognitive functioning in older patients. In this study, we aimed to characterize the long-term cognitive effects of ECT in patients with late-life depression, using an extensive neuropsychological battery. METHODS: A total of 110 patients aged 55 years and older with unipolar depression, referred for ECT were included. The neuropsychological test battery was assessed prior to ECT and 6 months after the last ECT session. RESULTS: There were no statistically significant group-level changes from baseline to 6 months post-ECT in any of the neuropsychological measurements. Individual differences in cognitive performance were detected using the Reliable Change Index. CONCLUSION: Patients with late-life depression do not show deleterious cognitive effects 6 months following an ECT index course, although there are considerable differences at an individual level. Clinicians should not hesitate to prescribe ECT in older patients, as most of these patients will tolerate the treatment course and a small group will even experience a cognitive enhancement. However, clinicians should be aware that a small group of patients can experience cognitive side-effects. Further study is needed to predict which patients have a higher risk of developing cognitive side-effects.

The course of apathy in late-life depression treated with electroconvulsive therapy; a prospective cohort study.

OBJECTIVES: Apathy, a lack of motivation, is frequently seen in older individuals, with and without depression, with substantial impact on quality of life. This prospective cohort study of patients with severe late-life depression treated with electroconvulsive therapy (ECT) aims to study the course of apathy and the predictive value of vascular burden and in particular white matter hyperintensities on apathy course. METHODS: Information on apathy (defined by a score of >13 on the Apathy Scale), depression severity, vascular burden, and other putative confounders was collected in at 2 psychiatric hospitals on patients with late-life depression (aged 55 to 87 years, N = 73). MRI data on white matter hyperintensities were available in 52 patients. Possible risk factors for apathy post-ECT were determined using regression analyses. RESULTS: After treatment with ECT, 52.0% (26/50) of the depression remitters still suffered from clinically relevant apathy symptoms. In the entire cohort, more patients remained apathetic (58.9%) than depressed (31.5%). Presence of apathy post-ECT was not associated with higher age, use of benzodiazepines, or severity of apathy and depression at baseline. Less response in depressive symptomatology after ECT predicted post-treatment apathy. The presence of vascular disease, diabetes mellitus and smoking, and white matter hyperintensities in the brain was not associated with post-treatment apathy. CONCLUSIONS: Apathy may perpetuate in individual patients, despite remission of depressive symptoms. In this cohort of patients with late-life depression, post-ECT apathy is not associated with white matter hyperintensities.

The use of triiodothyronine (T3) in the treatment of bipolar depression: A review of the literature.

BACKGROUND: There is a paucity of treatment options for bipolar depression. The use of triiodothyronine (T3) has been suggested as adjunctive treatment. METHODS: A search on Medline, Limo and ScienceDirect was performed using the search terms bipolar disorder, bipolar depression, treatment resistant, treatment refractory, thyroid hormones, triiodothyronine, T3, acceleration and augmentation. RESULTS: We retrieved three open studies, one comparative study, two double blind and one retrospective chart review. The three open studies observed improvement in respectively 56%, 75% and 79% of patients, the retrospective chart review noted improvement in 89% of cases and the mirror design showed improvement in 66%. In the comparative study T3 performed significantly better than placebo. The only randomized double blind study could not prove any substantial difference between T3 and placebo. LIMITATIONS: Available studies are scarce and flawed. All have (very) low number of subjects: overall, only 353 subjects and only 194 of which in prospective trials. In only two of the prospective trials bipolar patients were analyzed separately. Comparing the studies is hampered by a high variability in assessment tools, baseline medication and degree of treatment-resistance. CONCLUSIONS: The few available studies are small and flawed. They do show promising results. We found many clues suggesting that T3 could augment and accelerate treatment response not only with antidepressants, but also with lithium and perhaps with other treatment options, that it might protect against rapid cycling bipolar disorder, as well as against relapse during the first few years of treatment.

[Brain stimulation: the most direct form of neurostimulation]. / Hersenstimulatie: de meest directe vorm van neuromodulatie.

BACKGROUND: Brain stimulation is the most direct form of neuromodulation. Direct brain stimulation is an older procedure that has taken various forms, but 'non-invasive brain stimulation' is a more recent development. AIM: To provide an overview of the current arsenal of non-invasive brain stimulation techniques. METHOD: We discuss the underlying principles, the pros and cons, and the applicability of non-invasive brain stimulation in experimental research and treatment of neuropsychiatric disorders. RESULTS: Non-invasive brain stimulation is a direct form of neuromodulation, which is not invasive, harmful or painful. Its effects are in principle temporary, which makes the technique suitable for experimental research. At the same time, temporary effects can have lasting clinical consequences, if they target neuroplasticity to aid rehabilitation or alleviate symptoms. CONCLUSION: Whereas the value of non-invasive brain stimulation for research purposes is undisputed, its efficacy and value as a treatment for neuropsychiatric disorders are still being debated. Nevertheless, the accumulated evidence about the clinical efficacy of the treatment for certain disorders is sufficiently compelling to start thinking about European regulations and standard medical insurance coverage.

[ResPECT - a decade of Flemish-Dutch ECT research]. / ResPECT ­ een decennium Vlaams-Nederlands onderzoek naar elektroconvulsietherapie.

BACKGROUND: There is increasing clinical and scientific interest in electroconvulsive therapy (ECT). AIM: To provide an overview of the main research findings of the Flemish-Dutch research consortium ResPECT. METHOD: We report on our review of the relevant literature. RESULTS: Our studies confirm that ECT is one of the most efficient treatments for depression in later life and for depression with psychotic features. Older people with age-related brain pathology can respond well to ECT. It is still preferable to apply a standard pulse-width because this increases the efficacy of the treatment and minimises the cognitive impact. Even vulnerable older people can react favourably to ECT. CONCLUSION: Recent findings of the ResPECT consortium are providing new insights that are applicable in daily clinical practice. Research into mechanisms of action can also increase our understanding of the pathophysiology of severe depression.

[Doctor, will I get my memory back? Electroconvulsive therapy and cognitive side-effects in daily practice]. / Dokter, komt mijn geheugen terug? Elektroconvulsietherapie en cognitieve bijwerkingen in de praktijk.

BACKGROUND: Patients undergoing or about to undergo electroconvulsive therapy (ECT) are often afraid they will experience negative cognitive side-effects. AIM: To answer questions that patients and referring clinicians often ask about cognitive problems that can result from ECT. METHOD: To discuss, on the basis of clinical perception and literature, the cognitive problems resulting from ECT. RESULTS: The cognitive problems resulting from ect are threefold: short-term postictal confusion (immediately after the treatment), anterograde amnesia and retrograde amnesia. A patient affected by anterograde amnesia, is temporarily less able to remember what he or she has experienced over a period of three months after treatment. The brain of a patient with retrograde amnesia is unable to retrieve or remember information or procedures 'saved' before the treatment took place. More specifically the patient with retrograde amnesia has three main types of problems: semantic memory problems (relating to facts), episodic memory problems (no longer able to retrieve memories concerning non-personal events), and procedural memory problems (no longer able to operate various devices). It is difficult to predict which patients will experience cognitive problems as a result from ect and to what extent. However, the problems are not intensified by maintenance treatment. Factual and autobiographical memory problems following ect-induced retrograde amnesia seems to have a more permanent character. According to the Dutch guidelines for ECT, cognitive side-effects need to be monitored. If patients are monitored before and after ect, they can be given a more targeted psycho-education and eventually a more targeted training course. CONCLUSION: We conclude that in clinical practice increasing attention is being given to ECT-related cognitive side-effects. Clearly, however, more consideration needs to be given to inter-individual variability. Cognitive monitoring is advisable because the course of the side-effects of ect must be followed and evaluated.