Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: A multisite randomized controlled trial.

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PRACTICE GUIDELINE FOR THE Treatment of Patients With Major Depressive Disorder

Most patients treated for an episode of unipolar or bipolar major depression are treatment resistant in the sense that the majority do not achieve full remission with the first somatic or psychosocial treatment they receive. Little attention has been given to formalizing criteria for evaluating the nature and extent of treatment resistance, even though determining the adequacy and outcome of prior treatment trials is key in clinical decision making about subsequent treatment. Furthermore, determining the adequacy of prior treatment is essential since substantial evidence indicates that large numbers of depressed patients are undertreated, resulting in prolonged episodes and the appearance of "pseudoresistance." Adequacy of antidepressant treatment trials should be defined in terms of thresholds for the dosage and duration of medication, adherence, and clinical outcome. The Antidepressant Treatment History Form is presented as one method to formalize the evaluation of treatment adequacy and treatment resistance.

/pdf/the-definition-and-meaning-of-treatment-resistant-depression-2c9i0vnoca.pdf

The definition and meaning of treatment-resistant depression.

Background Controversy persists about the use of right unilateral (RUL) and bilateral (BL) electroconvulsive therapy (ECT). While RUL ECT results in less severe short-term and long-term cognitive effects, there is concern that it is less efficacious than BL ECT. Methods In a double-blind study, 80 depressed patients were randomized to RUL ECT, with electrical dosages 50%, 150%, or 500% above the seizure threshold, or BL ECT, with an electrical dosage 150% above the threshold. Depression severity and cognitive functioning were assessed before, during, immediately after, and 2 months after ECT. Compared with baseline, responders had at least a 60% reduction in symptom scores 1 week after ECT, and were monitored for relapse for 1 year. Results High-dosage RUL and BL ECT were equivalent in response rate (65%) and approximately twice as effective as low-dosage (35%) or moderate-dosage (30%) unilateral ECT. During the week after the randomized phase, BL ECT resulted in greater impairment than any dosage of unilateral ECT in several measures of anterograde and retrograde memory. Two months after ECT, retrograde amnestic deficits were greatest among patients treated with BL ECT. Thirty-three (53%) of the 62 patients who responded to ECT relapsed, without treatment group differences. The relapse rate was greater in patients who had not responded to adequate pharmacotherapy prior to ECT and who had more severe depressive symptoms after ECT. Conclusion Right unilateral ECT at high dosage is as effective as a robust form of BL ECT, but produces less severe and persistent cognitive effects.

/pdf/a-prospective-randomized-double-blind-comparison-of-5casii4r9h.pdf

A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities.

Objectives: To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility. Methods: Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders. Results: The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care.

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Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

Objective: Traditionally, it has been widely assumed that the likelihood of response to ECT is independent ofthe adequacy ofprevious treatment with antidepressant medications. However, recent research has raised the possibility that medication-resistant patients with depression have a poorer clinical ECT outcome than patients who have not failed previous adequate medication trials. Method: Medication resistance of 100 patients with primary, unipolar, nonpsychotic major depression was evaluated during the index episode with the Antidepressant Treatment History Form. Patients were recruited and treated with ECT at three sites; standardized ECT and clinical assessment procedures were used. Clinical outcome was assessed immediately and 1 week after completion of the ECT course. Results: Patients who previously had failed one or more adequate antidepressant medication trials were less likely to respond to subsequent ECT than patients not known to be medication resistant. This finding held within each study site, whether clinical response was assessed categorically or in terms of the magnitude of symptomatic improvement and after the authors accounted for other potential predictors of clinical outcome. Resistance to heterocyclic antidepressants predicted poorer outcome after ECT, while resistance to selective serotonin reuptake inhibitors and monoamine oxidase inhibitors did not show significant predictive relations. Conclusions: While a substantial percentage of medication-resistant patients respond to ECT, clinical outcome in this group is inferior to that of patients without established medication resistance. The predictive power ofmedication resistance is generalizable across diverse clinical settings, particularly for heterocyclic antidepressants, which perhaps suggests an overlap in the mechanisms ofactions of ECT and this medication class. (AmJ Psychiatry 1996; 153:985-992)

Resistance to Antidepressant Medications and Short-Term Clinical Response to ECT

Among 48 patients with diagnoses of depression according to DSM-III, there was a significant relation between therapeutic failure of unilateral ECT, as measured by scores on the Hamilton Rating Scale for Depression, and the concomitant use of a benzodiazepine. Of the 34 patients who showed a good therapeutic response to unilateral ECT, those taking benzodiazepines had smaller changes in their Hamilton depression ratings from before treatment to after treatment and were more symptomatic at the end of the course of ECT. Thus, when patients take benzodiazepines during a course of unilateral ECT, the maximum therapeutic response may be compromised.

Stephani Stephens

Papers

Resistance to Antidepressant Medications and Short-Term Clinical Response to ECT

Evidence for less improvement in depression in patients taking benzodiazepines during unilateral ECT.

A placebo-controlled evaluation of vasopressin for ECT-induced memory impairment.

Choosing an electroconvulsive therapy device.