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Electroconvulsive therapy for depression
Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.ORCID iD: 0000-0001-7454-3065
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Aim: The overarching aims of the thesis were to identify clinical characteristics that predict the outcomes of depressed patients treated inclinical practice by ECT, and to elucidate the effectiveness of continuation ECT at preventing relapses and recurrences.

Methods: The studies included a retrospective chart review, three studies based on a quality register for ECT, and a randomized controlled trial(RCT) examining the effectiveness of continued ECT.

Results: The overall response rate to ECT was 80%. Patients with psychotic depression (89%), older patients (84%), and inpatients (83%) had the highest response rates. Patients with personality disorders (66%) and outpatients (66%) had the lowest response rates. With regard to patients on sick leave, 59%, 71% and 88% of patients regained occupational functioning 6, 12 and 24 months after ECT, respectively. The rate of hospitalisation after ECT was high, with rates of 25%, 34%and 44% 6, 12 and 24 months after ECT, respectively. The relapse rate was higher in patients that were taking benzodiazepines and lower in patients that were taking lithium.

The relapse rate was significantly lower in patients treated with continued ECT in combination with pharmacotherapy (32%) than in those treated with pharmacotherapy alone (61%). This difference was particularly pronounced in medication-resistant patients (31% vs. 85%)

Conclusions: The short-term response rate to ECT is relatively high in all patient subgroups, and is particularly high in older patients, inpatients and patients with severe depression. Patients often regain occupational functioning after ECT; however, this takes a considerably longer time than that required for symptom relief. Nevertheless, the relapse and recurrence rates of patients are high in the years after ECT. Continuation ECT and lithium treatment can be combined with antidepressants to reduce the risk of relapse and recurrence. Further RCTs are required to define the indications for continuation ECT and lithium treatment.

Place, publisher, year, edition, pages
Örebro: Örebro universitet , 2013. , p. 89
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 85
Keywords [en]
electroconvulsive therapy, mood disorders, depressive disorder, major, bipolar disorder, treatment outcome, recurrence
National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
URN: urn:nbn:se:oru:diva-28663ISBN: 978-91-7668-932-5 (print)OAI: oai:DiVA.org:oru-28663DiVA, id: diva2:615555
Public defence
2013-05-24, Bohmanssonsalen Universitetssjukhuset, Södra Grev Rosengatan, Örebro, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2013-04-11 Created: 2013-04-11 Last updated: 2017-10-17Bibliographically approved
List of papers
1. Predictors of the short-term responder rate of Electroconvulsive therapy in depressive disorders: a population based study
Open this publication in new window or tab >>Predictors of the short-term responder rate of Electroconvulsive therapy in depressive disorders: a population based study
2012 (English)In: BMC Psychiatry, ISSN 1471-244X, E-ISSN 1471-244X, Vol. 12, article id 115Article in journal (Refereed) Published
Abstract [en]

Background: The aim of the present study is to investigate the responder rate of Electroconvulsive therapy, ECT, in clinical routine work and to define clinical characteristics predictive of response to ECT. The main hypothesis is that the responder rate of ECT might be lower in clinical routine than in controlled trials.

Methods: This is a population-based study of all patients (N = 990) treated with ECT for depressive disorders, between 2008-2010 in eight hospitals in Sweden. Patients with Clinical Global Impression-Improvement scores of 1 or 2 (much improved) within one week after ECT were considered responders to ECT. The predictive values of single clinical variables were tested by means of chi-squared tests and the relative importance was tested in a logistic regression analysis.

Results: The responder rate was 80.1%. A higher proportion of older patients (>50 years) responded (84.3% vs. 74.2%, p < 0.001). Psychotically depressed patients responded better (88.9% vs. 81.5% for severely depressed and 72.8% for mildly depressed, p < 0.001). There were no significant differences in responder rates between patients suffering from bipolar, first or recurrent major depressive syndromes, or a depressive episode of schizoaffective disorder. Patients with personality disorder had a lower responder rate (66.2% vs. 81.4%, p < 0.001). Also, outpatients had a lower responder rate (66.3%) compared to inpatients (83.4%, p < 0.001). In the logistic regression analysis, inpatient status, psychotic symptoms, absence of schizoaffective disorder and older age were independent factors associated with response to ECT.

Conclusions This study focuses exclusively on the short term responder rate with ECT in clinical practice. Similarly to results from controlled trials a high responder rate is reported. Older patients, more severely ill patients, psychotically ill patients and patients without personality disorders had the highest responder rates. Inpatients may have better outcome with ECT than outpatients.

Place, publisher, year, edition, pages
London, United Kingdom: BioMed Central, 2012
Keywords
Electroconvulsive therapy, major depressive disorder, treatment outcome
National Category
Medical and Health Sciences Psychiatry
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-27587 (URN)10.1186/1471-244X-12-115 (DOI)000309711700001 ()22900754 (PubMedID)2-s2.0-84865055621 (Scopus ID)
Available from: 2013-02-15 Created: 2013-02-15 Last updated: 2017-12-06Bibliographically approved
2. Predictors of time to relapse/recurrence after electroconvulsive therapy in patients with major depressive disorder: a population-based cohort study
Open this publication in new window or tab >>Predictors of time to relapse/recurrence after electroconvulsive therapy in patients with major depressive disorder: a population-based cohort study
2011 (English)In: Depression Research and Treatment, ISSN 2090-1321, E-ISSN 2090-133X, Vol. 2011, p. 470985-Article in journal (Refereed) Published
Abstract [en]

Objective. The aim of the study is to define predictors of relapse/recurrence after electroconvulsive therapy, ECT, for patients with major depressive disorder. Methods. A study of all patients (n = 486) treated by means of ECT for major depressive disorder was performed. The data were derived from a regional quality register in Sweden. Psychiatric hospitalisation or suicide was used as a marker for relapse/recurrence. Results. The relapse/recurrence rate within one year after ECT was 34%. Factors associated with increased risk of relapse/recurrence included comorbid substance dependence and treatment with benzodiazepines or antipsychotics during the follow-up period. Conclusions. Within the first years after ECT, relapses/recurrences leading to hospitalisation or suicide are common. Treatment with lithium might be beneficial, while benzodiazepines, antipsychotics, or continuation ECT does not seem to significantly reduce the risk of relapse/recurrence.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:oru:diva-27588 (URN)10.1155/2011/470985 (DOI)22110913 (PubMedID)
Available from: 2013-02-15 Created: 2013-02-15 Last updated: 2017-12-06Bibliographically approved
3. Continuation electroconvulsive therapy with pharmacotherapy versus pharmacotherapy alone for prevention of relapse of depression: A Randomized Controlled Trial
Open this publication in new window or tab >>Continuation electroconvulsive therapy with pharmacotherapy versus pharmacotherapy alone for prevention of relapse of depression: A Randomized Controlled Trial
Show others...
2013 (English)In: Journal of ECT, ISSN 1095-0680, E-ISSN 1533-4112, Vol. 29, no 2, p. 86-92Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: The primary aim of the study was to test the hypothesis that relapse prevention with continuation electroconvulsive therapy (ECT) plus pharmacotherapy is more effective than pharmacotherapy alone after a course of ECT for depression.

METHODS: A multicenter, nonblinded, randomized controlled trial with 2 parallel groups was performed from 2008 to 2012 in 4 hospitals in Sweden. Patients eligible had unipolar or bipolar depression and had responded to a course of ECT. The patients (n = 56) were randomly assigned (1:1) to receiving either 29 treatments of continuation ECT with pharmacotherapy or pharmacotherapy alone for 1 year. The pharmacotherapy consisted of antidepressants (98%), lithium (56%), and antipsychotics (30%). The main outcome was relapse of depression within 1 year. Relapse was defined as 20 or more points on the Montgomery Åsberg Depression Rating Scale or inpatient psychiatric care or suicide or suspected suicide. All 56 patients randomized were analyzed according to an intention to treat analysis.

RESULTS: Sixty-one percent of the patients treated with pharmacotherapy versus 32% of the patients treated with ECT plus pharmacotherapy relapsed within 1 year (P = 0.036). The Cox proportional hazard ratio was 2.32 (1.03-5.22).Cognitive function and memory measures were stable for patients without relapse in both groups.One suspected suicide and 3 suicide attempts by intoxication occurred, all in the pharmacotherapy-alone group.

CONCLUSIONS: The post-ECT relapse rates were substantial in both treatment groups with a statistically significant advantage for combined treatment with pharmacotherapy and continuation ECT. Further studies are needed to define indications for continuation ECT, pharmacotherapy, and their combination.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2013
National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-27585 (URN)10.1097/YCT.0b013e318276591f (DOI)000319457700012 ()23303421 (PubMedID)2-s2.0-84880136961 (Scopus ID)
Note

Funding agency:

Uppsala-Örebro Regional Research Council

Research Committee of Örebro County Council  

Available from: 2013-02-15 Created: 2013-02-15 Last updated: 2018-05-17Bibliographically approved
4. Rehospitalization rate after continued electroconvulsive therapy: a retrospective chart review of patients with severe depression
Open this publication in new window or tab >>Rehospitalization rate after continued electroconvulsive therapy: a retrospective chart review of patients with severe depression
2011 (English)In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 65, no 1, p. 26-31Article in journal (Refereed) Published
Abstract [en]

Background: Electroconvulsive therapy, ECT, is an effective acute treatment for severe depression. Today ECT is usually discontinued when the patient’s depressive symptoms abate, although relapse is common. Some studies suggest that continuation ECT (cECT) may prevent relapse of depression, but there are few studies available.

Aims: The aim of this study was to describe the need for inpatient care before, during and after cECT. Methods: A retrospective chart. review was conducted of all patients (n=27) treated with cECT between 2005 and 2007 at Orebro University Hospital, Sweden. All patients were severely depressed at the initiation of index ECT. The DSM-IV diagnoses were major depression (n=19), bipolar depression (n=5) or schizoaffective depression (n=3).

Results: The hospital day quotient was lower (HDQ=15) during cECT (mean duration+/-standard deviation=104+/-74 days) than during the 3 years prior to cECT (HDQ=26). The rehospitalization rate was 43% within 6 months and 58% within 2 years after the initiation of cECT. Seven patients were rehospitalized while on cECT.

Conclusion: The need for inpatient care was reduced during cECT. However, rehospitalization was common. At the initiation of the cECT, the patients were improved by the index ECT. Also cECT was often terminated after rehospitalization, which contributed to the lowered hospital day quotient during cECT. Randomized clinical trials are needed to establish the efficacy of cECT. Clinical implications: Relapses and recurrences in depressed patients are common after ECT treatment. The results indicate that continuation ECT combined with pharmacotherapy might be an alternative treatment strategy.

Place, publisher, year, edition, pages
Informa Healthcare, 2011
Keywords
Continuation treatment, Depressive disorder, ECT, Electroconvulsive therapy
National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-17157 (URN)10.3109/08039488.2010.485327 (DOI)000286683100006 ()20482461 (PubMedID)2-s2.0-78751506533 (Scopus ID)
Available from: 2011-09-05 Created: 2011-09-02 Last updated: 2017-12-08Bibliographically approved
5. Predictors of regained occupational functioning after electroconvulsive therapy (ECT) in patients with major depressive disorder: a population based cohort study
Open this publication in new window or tab >>Predictors of regained occupational functioning after electroconvulsive therapy (ECT) in patients with major depressive disorder: a population based cohort study
2013 (English)In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 67, no 5, p. 326-333Article in journal (Refereed) Published
Abstract [en]

Aims: The aim of the present study is to investigate the rate of regained occupational functioning among patients treated with electroconvulsive therapy (ECT) for major depression and to define predictors of time to regained occupational functioning.

Methods: A nested cohort study was performed of patients treated by ECT for unipolar major depressive disorder registered in the Quality register for ECT and in the Swedish Social Insurance Agency registry. Predictive values of single clinical variables and their relative importance were tested with Cox regression analysis.

Results: 394 patients were identified. Of those, 266 were on non-permanent sick leave and 128 on disability pension during ECT. Within 1 year post-ECT, 71% of the patients with non-permanent sick leave regained occupational functioning. Factors independently associated with a statistically significant increased time to regained occupational functioning were longer duration of sick leave pre-ECT, milder depression pre-ECT, less complete improvement with ECT, benzodiazepine treatment after ECT and co-morbid substance dependence.

Conclusions: A large proportion of the patients do not return to work within several months post-ECT. Paradoxically, patients with more severe depression pre-ECT had a reduced time to regained occupational functioning, indicating a larger effect in this patients group of the treatment. Moreover, the period with sick leave compensation might be reduced if ECT is initiated within the first 3 months of sick leave.

Clinical implications: Most patients on non-permanent sick leave regain occupational functioning after ECT. However, it usually takes a few months even in symptomatically improved patients.

Place, publisher, year, edition, pages
Oxfordshire, United Kingdom: Taylor & Francis, 2013
National Category
Medical and Health Sciences Psychiatry
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-27586 (URN)10.3109/08039488.2012.745602 (DOI)000324776900006 ()23228156 (PubMedID)2-s2.0-84884507531 (Scopus ID)
Note

Journal website: http://informahealthcare.com/loi/psc

Available from: 2013-02-15 Created: 2013-02-15 Last updated: 2017-12-06Bibliographically approved

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