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  • 1.
    Ahmad, Irma
    et al.
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Sandberg, Matilda
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Brus, Ole
    Örebro University, School of Medical Sciences.
    Ekman, Carl Johan
    Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden.
    Hammar, Åsa
    Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway; Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.
    Landén, Mikael
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
    Lundberg, Johan
    Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden.
    Nordanskog, Pia
    Department of Clinical and Experimental Medicine, Center for Social and Affective Neuroscience, Faculty of Health Sciences, Linköping University, Linköping, Sweden; Department of Psychiatry, Region Östergötland, Linköping, Sweden.
    von Knorring, Lars
    Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Validity of diagnoses, treatment dates, and rating scales in the Swedish national quality register for electroconvulsive therapy2022In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 76, no 2, p. 96-103Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The Swedish national quality register for electroconvulsive therapy (Q-ECT) contains data on patients receiving treatment with electroconvulsive therapy (ECT) in Sweden.

    AIM: This study determined the validity of diagnoses, treatment dates, and rating scales in the Q-ECT by investigating the degree of accordance between data from the Q-ECT and patient records.

    MATERIALS AND METHODS: From January 2016 to December 2017, 200 treatment series were randomly selected from the Q-ECT. The corresponding patient records were requested from the treating hospitals. Data on the indicative diagnosis, dates for the first and the last ECT session, and rating scales were compared between the Q-ECT and patient records using (i) a strict and (ii) a liberal method of assessment. Using the liberal method, each variable was assessed as accordant if it belonged to the same diagnosis group, or if the dates differed by less than 1 week, or ratings differed by only 1 point on the Clinical Global Impression Scale (CGI- S), or no more than 3 points on the Montgomery Åsberg Depression Rating Scale between the Q-ECT and the patient record.

    RESULTS: A total of 179 patient records were received. The strict method of assessment showed an accordance of 89% or higher for all studied variables. The liberal method showed an accordance of 95% or higher.

    CONCLUSIONS: We conclude that data on the studied variables in the Q-ECT have high validity. However, limited use of some rating scales makes the results uncertain. Measures can be taken to further improve the data quality.

  • 2.
    Al-Wandi, Ahmed
    et al.
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Holmberg, Christoffer
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Landén, Mikael
    Institute of Neuroscience and Physiology, the Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    A systematic review and meta-analysis of maintenance treatment for psychotic depression2022In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 76, no 6, p. 442-450Article, review/survey (Refereed)
    Abstract [en]

    PURPOSE: To perform a systematic review on the use of maintenance treatment to prevent relapse and recurrence in patients with psychotic unipolar or bipolar depression.

    METHODS: We conducted an electronic search in December 2019 (and an updated search in July 2021) of four databases (PubMed, Embase, PsycINFO, and Cochrane) to identify controlled studies comparing the relapse rates of patients receiving maintenance treatment for psychotic unipolar depression and psychotic bipolar depression. A meta-analysis was made that included three studies comparing antidepressant (AD) and antipsychotic (AP) combination therapy with AD monotherapy. We used the GRADE tool to assess the quality of evidence.

    RESULTS: We included five randomized controlled trials fulfilling the inclusion criteria, making three comparisons: (a) AD + AP versus AD monotherapy; (b) AD + AP versus AP monotherapy; (c) AD + electroconvulsive therapy versus AD monotherapy. The included studies only examined patients with psychotic unipolar depression. The largest included study reported a statistically significant advantage of AD + AP compared with AD monotherapy. We made a meta-analysis of the three studies comparing AD + AP combination therapy with AD monotherapy, which included 195 patients and 56 events. The meta-analysis did not show a statistically significant difference between these treatments.

    CONCLUSIONS: Contrary to the finding of the largest study, we did not find a statistically significant difference between AD + AP combination therapy and AD monotherapy in the meta-analysis. There is insufficient evidence to support the superiority of any treatment modality as maintenance treatment for psychotic depression. Further studies are required.

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    A systematic review and meta-analysis of maintenance treatment for psychotic depression
  • 3.
    Al-Wandi, Ahmed
    et al.
    Örebro University, School of Medical Sciences. University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Landén, Mikael
    Institute of Neuroscience and Physiology, the Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Antipsychotics in the maintenance phase for psychotic depression2024In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 149, no 1, p. 6-17Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: This study aimed to associate antidepressants with versus without antipsychotics with readmission and suicide in patients with psychotic unipolar depression.

    METHODS: Swedish national registers were used to identify inpatients with psychotic unipolar depression, treated 2007-2016. The participants collected antidepressants with or without antipsychotics from a pharmacy within 14 days after discharge and were followed up for 2 years. The primary outcome was hospital readmission due to any psychiatric disorder, suicide attempt, or completed suicide. Cox regression was used to analyze the data, which were adjusted for sex, age, prior admissions, comorbidity, electroconvulsive therapy, and other pharmacological treatments.

    RESULTS: We identified 4391 patients, of which 2972 were in the antidepressant + antipsychotic combination therapy group, and 1419 were in the antidepressant monotherapy group. After 2 years, 42.3% and 36.6% of patients were readmitted or committed suicide in the combination therapy and monotherapy group, respectively. Monotherapy was significantly associated with a lower risk of reaching the outcome in the main analysis (hazard ratio = 0.86; 95% confidence interval: 0.77-0.95). The results went in the same direction in all sensitivity analyses.

    CONCLUSION: Our findings do not indicate any advantage of adding antipsychotics as adjunctive to antidepressants as maintenance treatment. Considering the wide use, known side effects, and the current lack of evidence supporting the benefit, further studies on the effect of antipsychotics in the maintenance phase of psychotic unipolar depression are urgently warranted.

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    Antipsychotics in the maintenance phase for psychotic depression
  • 4.
    Arnison, Tor
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Clinical Epidemiology and Biostatistics.
    Rask, Olof
    Department of Clinical Sciences Lund, Division of Child and Adolescent Psychiatry, Lund University, Lund, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Movahed Rad, Pouya
    Department of Clinical Sciences, Division of Adult Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden.
    Safety of and response to electroconvulsive therapy during pregnancy: Results from population‐based nationwide registries2023In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447Article in journal (Refereed)
    Abstract [en]

    Introduction: Psychiatric disorders are common during pregnancy, affecting up to 16% of pregnant women. Severe depression and anxiety have significant negative effects on the health of both the mother and the developing fetus. Electroconvulsive therapy (ECT) is considered a treatment option for pregnant women with severe psychiatric disorders when other treatments have been ineffective or pose risks to the fetus. Knowledge of the safety and efficacy of ECT during pregnancy, however, remains limited.

    Methods: Data were obtained from nationwide registries of pregnant women in Sweden who received ECT for a severe psychiatric disorder from January 2008 to December 2021. ECT-related outcomes in pregnant women were compared by propensity score matching with a group of non-pregnant women who also received ECT. Pregnancy-related outcomes were compared with two additional control groups: one consisting of the same group of women who did not receive ECT during another pregnancy and the other composed of pregnant women admitted to inpatient psychiatric care but who did not receive ECT, matched based on propensity score.

    Results: Ninety-five pregnant women received ECT during the study period, accounting for 97 pregnancies. The response rate to ECT in pregnant women (n = 54) was similar to the matched control group of non-pregnant women (74% vs. 65%; OR 1.61; 95% CI 0.79-3.27). Rates of adverse events related to ECT were similar to those in the control group. There were no pre-term births or severe adverse outcomes related to the pregnancy, that were close in time to ECT. Therefore, no adverse outcomes related to pregnancy and childbirth could be directly attributed to ECT. The likelihood of premature birth and a 5-min Apgar score <7 in the newborn were both significantly higher in the ECT group, compared with the matched non-ECT group (OR 2.33, 95% CI 1.15-4.73, p = 0.008, and OR 3.68, 95% CI 1.58-8.55, p < 0.001, respectively). By contrast, no significant differences were observed when women in the pregnant ECT group were compared with the same group lacking ECT during another pregnancy.

    Conclusions: ECT was associated with a positive treatment response in pregnant women with severe psychiatric disorders. The response rate to ECT was similar in pregnant and non-pregnant women. Nevertheless, the risks of premature birth and of a slightly poorer condition in newborns were higher in women who did than did not receive ECT, emphasizing the need for increased attention to severe psychiatric disorders during pregnancy.

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  • 5.
    Bejerot, Susanne
    et al.
    Örebro University, School of Medical Sciences. Faculty of Health and Medical Sciences, University Health Care Research Centre, Örebro University, Örebro, Sweden.
    Eklund, Daniel
    Örebro University, School of Medical Sciences.
    Hesser, Hugo
    Örebro University, School of Behavioural, Social and Legal Sciences.
    Hietala, Max Albert
    Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.
    Kariis, Tarmo
    Karlstad Central Hospital, Region Värmland, Karlstad, Sweden.
    Lange, Niclas
    Örebro University, School of Medical Sciences.
    Lebedev, Alexander
    Center for Psychiatry Research (CPF), Center for Cognitive and Computational Neuropsychiatry (CCNP), Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Montgomery, Scott
    Örebro University, School of Medical Sciences. Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences.
    Petrovic, Predrag
    Center for Psychiatry Research (CPF), Center for Cognitive and Computational Neuropsychiatry (CCNP), Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Söderbergh, Annika
    Department of Rheumatology, Örebro University Hospital, Örebro, Sweden.
    Thunberg, Per
    Örebro University, School of Medical Sciences. Department of Radiology and Medical Physics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Center for Experimental and Biomedical Imaging in Örebro (CEBIO), Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Wikström, Sverre
    Örebro University, School of Medical Sciences. Centre for Clinical Research, County Council of Värmland, Karlstad, Sweden.
    Humble, Mats B.
    Örebro University, School of Medical Sciences.
    Study protocol for a randomized controlled trial with rituximab for psychotic disorder in adults (RCT-Rits)2023In: BMC Psychiatry, E-ISSN 1471-244X, Vol. 23, no 1, article id 771Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The role of inflammation in the aetiology of schizophrenia has gained wide attention and research on the association shows an exponential growth in the last 15 years. Autoimmune diseases and severe infections are risk factors for the later development of schizophrenia, elevated inflammatory markers in childhood or adolescence are associated with a greater risk of schizophrenia in adulthood, individuals with schizophrenia have increased levels of pro-inflammatory cytokines compared to healthy controls, and autoimmune diseases are overrepresented in schizophrenia. However, treatments with anti-inflammatory agents are so far of doubtful clinical relevance. The primary objective of this study is to test whether the monoclonal antibody rituximab, directed against the B-cell antigen CD20 ameliorates psychotic symptoms in adults with schizophrenia or schizoaffective disorder and to examine potential mechanisms. A secondary objective is to examine characteristics of inflammation-associated psychosis and to identify pre-treatment biochemical characteristics of rituximab responders. A third objective is to interview a subset of patients and informants on their experiences of the trial to obtain insights that rating scales may not capture.

    METHODS: A proof-of-concept study employing a randomised, parallel-group, double-blind, placebo-controlled design testing the effect of B-cell depletion in patients with psychosis. 120 participants with a diagnosis of schizophrenia spectrum disorders (SSD) (ICD-10 codes F20, F25) will receive either one intravenous infusion of rituximab (1000 mg) or saline. Psychiatric measures and blood samples will be collected at baseline, week 12, and week 24 post-infusion. Brief assessments will also be made in weeks 2 and 7. Neuroimaging and lumbar puncture, both optional, will be performed at baseline and endpoints. Approximately 40 of the patients and their informants will be interviewed for qualitative analyses on the perceived changes in well-being and emotional qualities, in addition to their views on the research.

    DISCUSSION: This is the first RCT investigating add-on treatment with rituximab in unselected SSD patients. If the treatment is helpful, it may transform the treatment of patients with psychotic disorders. It may also heighten the awareness of immune-psychiatric disorders and reduce stigma.

    TRIAL REGISTRATION: NCT05622201, EudraCT-nr 2022-000220-37 version 2.1. registered 14th of October 2022.

  • 6.
    Brus, Ole
    et al.
    Örebro University, School of Medical Sciences.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Carlborg, Andreas
    Karolinska Institutet, Department of Clinical Neuroscience, Stockholm, Sweden.
    Engström, Ingemar
    Örebro University, School of Medical Sciences. University Health Care Research Center.
    von Knorring, Lars
    Uppsala University, Department of Neuroscience, Psychiatry.
    Ljung, Tomas
    Clinic of Psychiatry, Falun, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Long term effect of continuation electroconvulsive therapy for depressive patients: a randomized controlled trialManuscript (preprint) (Other academic)
  • 7.
    Brus, Ole
    et al.
    Örebro University, School of Medical Sciences. Clinical epidemiology and biostatistics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Clinical epidemiology and biostatistics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Carlborg, Andreas
    Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Engström, Ingemar
    Örebro University, School of Medical Sciences. University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    von Knorring, Lars
    Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Long-Term Effect of Maintenance Electroconvulsive Therapy in Patients With Depression-Data From a Small Randomized Controlled Trial2024In: Journal of ECT, ISSN 1095-0680, E-ISSN 1533-4112Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: This study aimed to compare the long-term effects of maintenance electroconvulsive therapy (M-ECT) with medication and medication only in patients with depression.

    METHODS: A randomized controlled trial of 1 year of M-ECT with medication or medication only investigated relapse/recurrence among 56 patients in remission after electroconvulsive therapy (ECT) for depression was conducted. The results of the first year are published already and showed a significant advantage of M-ECT with medication.The current study was a long-term follow-up. When the randomized treatment allocation ended, medication was continued in both groups but M-ECT was terminated. Patients were followed for up to 10 years via Swedish national registers until the study endpoint of a new psychiatric diagnosis as an inpatient, suicide, suspected suicide, or death of another cause. Time to relapse was compared between the M-ECT with medication group and the medication-only group using Kaplan-Meier estimates.

    RESULTS: The median follow-up time was 6.5 years for the M-ECT and medication group and 3.1 years for the medication-only group. One year after randomization 22 patients remained in the M-ECT and medication group, and 14 patients remained in the medication-only group. Relapse patterns between the treatment groups after the completion of M-ECT seemed to be similar according to visual inspection.

    CONCLUSIONS: This long-term follow-up study suggests that most of the benefit achieved during the treatment period with M-ECT is maintained over several years, but the small sample size, with accompanying large statistical imprecision, makes the results uncertain. More long-term studies of M-ECT are required.Trial registration: ClinicalTrials.gov identifier: NCT00627887.

  • 8.
    Brus, Ole
    et al.
    Örebro University, School of Medical Sciences.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Gustafsson, E.
    Department of Psychiatry, Umeå University Hospital, Umeå, Sweden.
    Hultén, Martin
    Psychiatric Neuromodulation Unit (PNU), Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden.
    Landén, Mikael
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
    Lundberg, Johan
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.
    Nordanskog, Pia
    Center for Social and Affective Neuroscience, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Self-assessed remission rates after electroconvulsive therapy of depressive disorders2017In: European psychiatry, ISSN 0924-9338, E-ISSN 1778-3585, Vol. 45, p. 154-160, article id S0924-9338(17)32917-6Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Electroconvulsive therapy (ECT) effectively treats severe depression, but not all patients remit. The aim of the study was to identify clinical factors that associate with ECT-induced remission in a community setting.

    METHODS: Depressed patients who underwent ECT in 2011-2014 were identified from the Swedish National Quality Register for ECT. Remission was defined as self-rated Montgomery-Åsberg Depression Rating Scale scores of 0-10 after ECT. Other registers provided data on previous antidepressant use, comorbidities, and demographics.

    RESULTS: Of 1671 patients fulfilling the inclusion criteria, 42.8% achieved remission. Older age, education length over 9 years, psychotic symptoms, shorter duration of preceding antidepressant use, pulse width stimulus≥0.50ms, absence of substance use disorders, anxiety diagnosis, lamotrigine, and benzodiazepines, were associated with remission.

    CONCLUSIONS: This study shows that psychotic subtype of depression and older age are clinically relevant predictors of a beneficial ECT effect. Additionally, ECT outcomes can be further improved by optimizing the treatment technique and concomitant medication.

  • 9.
    Brus, Ole
    et al.
    Örebro University, School of Medical Sciences.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Hammar, Åsa
    Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway; Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.
    Landén, Mikael
    Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Lundberg, Johan
    Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden; Stockholm County Council, Stockholm, Sweden.
    Nordanskog, Pia
    Center for Social and Affective Neuroscience, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden; Department of Psychiatry, Region Östergötland, Linköping, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Lithium for suicide and readmission prevention after electroconvulsive therapy for unipolar depression: population-based register study2019In: BJPsych Open, E-ISSN 2056-4724, Vol. 5, no 3, article id e46Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Electroconvulsive therapy (ECT) is effective for unipolar depression but relapse and suicide are significant challenges. Lithium could potentially lower these risks, but is used only in a minority of patients.AimsThis study quantifies the effect of lithium on risk of suicide and readmission and identifies factors that are associate with readmission and suicide.

    METHOD: This population-based register study used data from the Swedish National Quality Register for ECT and other Swedish national registers. Patients who have received ECT for unipolar depression as in-patients between 2011 and 2016 were followed until death, readmission to hospital or the termination of the study at the end of 2016. Cox regression was used to estimate hazard ratios (HR) of readmission and suicide in adjusted models.

    RESULTS: Out of 7350 patients, 56 died by suicide and 4203 were readmitted. Lithium was prescribed to 638 (9%) patients. Mean follow-up was 1.4 years. Lithium was significantly associated with lower risk of suicide (P = 0.014) and readmission (HR 0.84 95% CI 0.75-0.93). The number needed to be treated with lithium to prevent one readmission was 16. In addition, the following factors were statistically associated with suicide: male gender, being a widow, substance use disorder and a history of suicide attempts. Readmission was associated with young age, being divorced or unemployed, comorbid anxiety disorder, nonpsychotic depression, more severe symptoms before ECT, no improvement with ECT, not receiving continuation ECT or antidepressants, usage of antipsychotics, anxiolytics or benzodiazepines, severity of medication resistance and number of previous admissions.

    CONCLUSIONS: More patients could benefit from lithium treatment.

  • 10.
    Brus, Ole
    et al.
    Örebro University, School of Medical Sciences.
    Nordanskog, Pia
    Center for Social and Affective Neuroscience, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden; Department of Psychiatry, Region Östergötland, Linköping, Sweden.
    Båve, Ullvi
    Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Hammar, Åsa
    Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway; Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.
    Landén, Mikael
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
    Lundberg, Johan
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Subjective Memory Immediately Following Electroconvulsive Therapy2017In: Journal of ECT, ISSN 1095-0680, E-ISSN 1533-4112, Vol. 33, no 2, p. 96-103Article in journal (Refereed)
    Abstract [en]

    Objectives: The aims of the present study were to describe the short-term rate of subjective memory worsening (SMW) and identify factors of importance for SMW in a large clinical sample treated for depression with electroconvulsive therapy (ECT).

    Methods: This register-based study included 1212 patients from the Swedish National Quality Register for ECT. Subjective memory worsening was defined as a 2-point worsening on the memory item of the Comprehensive Psychopathological Rating Scale from before to within 1 week after treatment. Associations between patient characteristics and treatment factors were examined using logistic regression.

    Results: Subjective memory worsening was experienced in 26%. It was more common in women than in men (31% vs 18%; P < 0.001) and more common in patients aged 18 to 39 years than in patients 65 years or older (32% vs 22%; P = 0.008). Patients with less subjective memory disturbances before ECT had a greater risk of SMW. Patients in remission after ECT had a lower risk of SMW. A brief pulse width stimulus gave higher risk of SMW compared with ultrabrief pulse (odds ratio, 1.61; 95% confidence interval, 1.05-2.47).

    Conclusions: Subjective memory worsening is reported by a minority of patients. However, young women are at risk of experiencing SMW. Ultrabrief pulse width stimulus could be considered for patients treated with unilateral electrode placement who experience SMW. Each patient should be monitored with regard to symptoms and adverse effects, and treatment should be adjusted on an individual basis to maximize the clinical effect and with efforts to minimize the cognitive adverse effects.

  • 11.
    Cato, Ville
    et al.
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Cente.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Cente.
    Sellin Jönsson, Tabita
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Cente.
    Association between benzodiazepines and suicide risk: a matched case-control study2019In: BMC Psychiatry, E-ISSN 1471-244X, Vol. 19, no 1, article id 317Article in journal (Refereed)
    Abstract [en]

    Background: It is unclear whether benzodiazepines increase the risk of suicide. The aim of this study was to test the hypothesis that benzodiazepines are associated with an increased risk of suicide, by comparing psychopharmacological interventions between psychiatric patients who committed suicide and a group of matched controls.

    Methods: The case group comprised 154 psychiatric patients (101 men, 53 women; age range: 13-96 years) who had committed suicide in orebro County, Sweden. Control psychiatric patients matched by age, sex, and main psychiatric diagnosis were selected for each case. Binary logistic regression was used to calculate odds ratios in unadjusted and adjusted models.

    Results: Benzodiazepine prescriptions were more common among cases than controls (65/154 [42.2%] versus 43/154 [27.9%], p = 0.009, odds ratio: 1.89 [95% CI: 1.17-3.03]). This association remained significant in a model adjusted for previous suicide attempts and somatic hospitalizations (odds ratio: 1.83 [95% CI: 1.06-3.14]). No statistically significant differences were seen between the groups in the use of any other subtype of psychopharmaceutical agent.

    Conclusions: These data indicate that benzodiazepine use may increase the risk of suicide. However, this study is limited by the potential for indication bias.

  • 12.
    Clements, Caitlin C.
    et al.
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA.
    Karlsson, Robert
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Lu, Yi
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Juréus, Anders
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Rück, Christian
    Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Stockholm County Council, Karolinska University Hospital, Huddinge, Sweden.
    Andersson, Evelyn
    Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Stockholm County Council, Karolinska University Hospital, Huddinge, Sweden.
    Boberg, Julia
    Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Stockholm County Council, Karolinska University Hospital, Huddinge, Sweden.
    Pedersen, Nancy L.
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Bulik, Cynthia M.
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Psychiatry, University of North Carolina, Chapel Hill, NC, USA; Department of Nutrition, University of North Carolina, Chapel Hill, NC, USA.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences.
    Pålsson, Erik
    Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
    Sullivan, Patrick F.
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Psychiatry, University of North Carolina, Chapel Hill, NC, USA; Department of Genetics, University of North Carolina, Chapel Hill, NC, USA.
    Landén, Mikael
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
    Genome-wide association study of patients with a severe major depressive episode treated with electroconvulsive therapy2021In: Molecular Psychiatry, ISSN 1359-4184, E-ISSN 1476-5578, Vol. 26, no 6, p. 2429-2439Article in journal (Refereed)
    Abstract [en]

    Although large genome-wide association studies (GWAS) of major depressive disorder (MDD) have identified many significant loci, the SNP-based heritability remains notably low, which might be due to etiological heterogeneity in existing samples. Here, we test the utility of targeting the severe end of the MDD spectrum through genome-wide SNP genotyping of 2725 cases who received electroconvulsive therapy (ECT) for a major depressive episode (MDE) and 4035 controls. A subset of cases (n = 1796) met a narrow case definition (MDE occurring in the context of MDD). Standard GWAS quality control procedures and imputation were conducted. SNP heritability and genetic correlations with other traits were estimated using linkage disequilibrium score regression. Results were compared with MDD cases of mild-moderate severity receiving internet-based cognitive behavioral therapy (iCBT) and summary results from the Psychiatric Genomics Consortium (PGC). The SNP-based heritability was estimated at 29-34% (SE: 6%) for the narrow case definition, considerably higher than the 6.5-8.0% estimate in the most recent PGC MDD study. Our severe MDE cases had smaller genetic correlations with neurodevelopmental disorders and neuroticism than PGC MDD cases but higher genetic risk scores for bipolar disorder than iCBT MDD cases. One genome-wide significant locus was identified (rs114583506, P = 5e-8) in an intron of HLA-B in the major histocompatibility locus on chr6. These results indicate that individuals receiving ECT for an MDE have higher burden of common variant risk loci than individuals with mild-moderate MDD. Furthermore, severe MDE shows stronger relations with other severe adult-onset psychiatric disorders but weaker relations with personality and stress-related traits than mild-moderate MDD. These findings suggest a different genetic architecture at the severest end of the spectrum, and support further study of the severest MDD cases as an extreme phenotype approach to understand the etiology of MDD.

  • 13.
    Eggers, K. M.
    et al.
    Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
    Hjort, M.
    Department of Medical Sciences, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
    Baron, T.
    Department of Medical Sciences, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
    Jernberg, T.
    Department of Clinical Sciences, Cardiology, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden.
    Nordenskjöld, A. M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiology.
    Tornvall, P.
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden.
    Lindahl, B.
    Department of Medical Sciences, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
    Morbidity and cause-specific mortality in first-time myocardial infarction with nonobstructive coronary arteries2019In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 285, no 4, p. 419-428Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) is receiving increasing interest as a prognostically adverse entity distinct from myocardial infarction with significant coronary artery disease (MI-CAD). However, data are still limited regarding long-term cardiovascular morbidity and cause-specific mortality in MINOCA.

    METHODS: This is a registry-based cohort study using data from patients admitted to Swedish coronary care units. We investigated various nonfatal outcomes (recurrent MI, hospitalization for heart failure or stroke) and fatal outcomes (cardiovascular, respiratory or cancer-related mortality) in 4069 patients without apparent acute cardiovascular disease, used as non-MI controls, 7266 patients with first-time MINOCA and 69 267 patients with first-time MI-CAD.

    RESULTS: Almost all event rates (median follow-up 3.8 years) increased in a stepwise fashion across the three cohorts [rates of major adverse events (MAE; composite of all-cause mortality, recurrent MI, hospitalization for heart failure or stroke): n = 268 (6.6%), n = 1563 (21.5%), n = 17 777 (25.7%), respectively]. Compared to non-MI controls, MINOCA patients had an adjusted hazard ratio (HR) of 2.12 (95% confidence interval 1.84-2.43) regarding MAE. MINOCA patients had a substantial risk of cardiovascular mortality and the highest numerical risks of respiratory and cancer-related mortality. Male sex, previous heart failure and chronic obstructive pulmonary disease had a stronger prognostic impact in MINOCA than in MI-CAD. Female MINOCA patients with atrial fibrillation were at particular risk.

    CONCLUSIONS: Patients with first-time MINOCA have a considerable risk of adverse events. This stresses the need for a comprehensive search of the cause of MINOCA, thorough treatment of underlying disease triggers and close follow-up.

  • 14.
    Ekman, Carl Johan
    et al.
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Sweden.
    Popiolek, Katarzyna
    Örebro University, School of Medical Sciences. University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Bodén, Robert
    Department of Neuroscience, Psychiatry, Uppsala University Hospital, Uppsala, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Lundberg, Johan
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Sweden.
    Outcome of transcranial magnetic intermittent theta-burst stimulation in the treatment of depression - A Swedish register-based study2023In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 329, p. 50-54Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is an established treatment of depression. The more recently introduced intermittent Theta-burst stimulation (iTBS) has shown significant superiority over sham-stimulation and equal effect sizes to a 10 Hz protocol in one clinical trial. The aim of the current study was to investigate the effectiveness and tolerability of iTBS in a naturalistic, clinical setting. Further, we explored demographical and clinical predictors of response.

    METHODS: Data was collected from seventeen rTMS-sites in Sweden between January 2018 and May 2021, through the Swedish National Quality register for repetitive Transcranial Magnetic Stimulation (Q-rTMS). We included 542 iTBS-treated patients with unipolar or bipolar depression. Outcome was assessed with Clinical Global Impression Severity and Improvement scores in an intention to treat analysis.

    RESULTS: The response rate was 42.1 % and 16.1 % reached remission. The response rate was significantly larger in the oldest age group compared to the youngest (odds ratio 3.46, 95 % confidence interval 1.65-7.22). Less severe level of depression (Montgomery-Åsberg depression rating scale self-assessment < 36) at baseline predicted response and remission. Only <1 % were much or very much worse after treatment. Drop-out rate was 10.9 %. No serious adverse events were reported.

    LIMITATIONS: Retrospective analysis of register data. No comparison group.

    CONCLUSIONS: In a clinical setting, iTBS was shown to be safe and tolerable and the response rate was similar to that reported from clinical trials. Older age-group and less severe illness predicted response.

  • 15.
    Ekstrand, Joakim
    et al.
    Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
    Fattah, Christian
    Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
    Persson, Marcus
    Department of Clinical Sciences, Faculty of Medicine, Lund University, Helsingborg, Sweden.
    Cheng, Tony
    Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden.
    Nordanskog, Pia
    Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
    Åkeson, Jonas
    Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden.
    Tingström, Anders
    Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
    Lindström, Mats B.
    Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences.
    Movahed Rad, Pouya
    Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
    Racemic Ketamine as an Alternative to Electroconvulsive Therapy for Unipolar Depression: A Randomized, Open-Label, Non-Inferiority Trial (KetECT)2022In: International Journal of Neuropsychopharmacology, ISSN 1461-1457, E-ISSN 1469-5111, Vol. 25, no 5, p. 339-349Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Ketamine has emerged as a fast-acting and powerful antidepressant, but no head to head trial has been performed, Here, ketamine is compared with electroconvulsive therapy (ECT), the most effective therapy for depression.

    METHODS: Hospitalized patients with unipolar depression were randomized (1:1) to thrice-weekly racemic ketamine (0.5 mg/kg) infusions or ECT in a parallel, open-label, non-inferiority study. The primary outcome was remission (Montgomery Åsberg Depression Rating Scale score ≤10). Secondary outcomes included adverse events (AEs), time to remission, and relapse. Treatment sessions (maximum of 12) were administered until remission or maximal effect was achieved. Remitters were followed for 12 months after the final treatment session.

    RESULTS: In total 186 inpatients were included and received treatment. Among patients receiving ECT, 63% remitted compared with 46% receiving ketamine infusions (P = .026; difference 95% CI 2%, 30%). Both ketamine and ECT required a median of 6 treatment sessions to induce remission. Distinct AEs were associated with each treatment. Serious and long-lasting AEs, including cases of persisting amnesia, were more common with ECT, while treatment-emergent AEs led to more dropouts in the ketamine group. Among remitters, 70% and 63%, with 57 and 61 median days in remission, relapsed within 12 months in the ketamine and ECT groups, respectively (P = .52).

    CONCLUSION: Remission and cumulative symptom reduction following multiple racemic ketamine infusions in severely ill patients (age 18-85 years) in an authentic clinical setting suggest that ketamine, despite being inferior to ECT, can be a safe and valuable tool in treating unipolar depression.

  • 16.
    Ekstrand, Joakim
    et al.
    Department of Clinical Sciences, Division of Adult Psychiatry Faculty of Medicine, Lund University, Lund, Sweden.
    Takamiya, Akihiro
    KU Leuven, Leuven Brain Institute, Department of Neurosciences, Neuropsychiatry, Leuven, Belgium; Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Hills Joint Research Laboratory for Future Preventive Medicine and Wellness, Keio University School of Medicine, Tokyo, Japan.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Kirov, George
    Centre for Neuropsychiatric Genetics & Genomics, Cardiff University School of Medicine Division of Psychological Medicine and Clinical Neuroscience, Cardiff, UK.
    Sienaert, Pascal
    Department of Neurosciences, University Psychiatric Center KU Leuven, Research Group Psychiatry, Academic Center for ECT and Neuromodulation (AcCENT), KU Leuven, Leuven, Belgium.
    Kellner, Charles
    Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
    Movahed Rad, Pouya
    Department of Clinical Sciences, Division of Adult Psychiatry Faculty of Medicine, Lund University, Lund, Sweden.
    Ketamine or ECT? What have we learned from the KetECT and ELEKT-D trials?2024In: International Journal of Neuropsychopharmacology, ISSN 1461-1457, E-ISSN 1469-5111, Vol. 27, no 1, article id pyad065Article in journal (Refereed)
    Abstract [en]

    Two recent clinical trials, KetECT and ELEKT-D, compared the effectiveness of ketamine and electroconvulsive therapy (ECT) for major depressive disorder. Notably, these trials reported marked differences in ECT's clinical outcomes of, with remission rates of 63% for KetECT and a strikingly lower rate of 22% for ELEKT-D, while the remission rates for ketamine were 46% and 38%, respectively. Considering that the primary objective of both trials was to compare the standard treatment (ECT) with an experimental intervention (ketamine), it is crucial to highlight the pronounced disparities in ECT's clinical outcomes. This article offers a comprehensive comparison of these trials while also exploring how patient characteristics, treatment protocols, and study designs may contribute to such pronounced outcome discrepancies. These differences highlight the heterogeneous nature of depression and underscore the need for personalized treatments. These studies also provide valuable insights into identifying the most suitable candidates for ketamine and ECT.

  • 17.
    Ernstsson, Olivia
    et al.
    Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden.
    Heintz, Emelie
    Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden; Centre for Health Economics, Informatics and Health Services Research, Stockholm Health Care Services, Stockholm, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. Faculty of Medicine and Health, University Health Care Research Centre, Örebro University, Örebro, Sweden.
    Johnson, Jeffrey A.
    School of Public Health, University of Alberta, Edmonton, Canada.
    Korkmaz, Seher
    Department of Digitalization and IT, Health and Care Administration, Stockholm, Sweden.
    Zethraeus, Niklas
    Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden.
    Association between pulse width and health-related quality of life after electroconvulsive therapy in patients with unipolar or bipolar depression: an observational register-based study2023In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725Article in journal (Refereed)
    Abstract [en]

    AIMS: To examine the association between pulse width and HRQoL measured within one week after electroconvulsive therapy (ECT) and at six-month follow-up in patients with unipolar or bipolar depression.

    METHODS: This was an observational register study using data from the Swedish National Quality Registry for ECT (2011-2019). Inclusion criteria were: age ≥18 years; index treatment for unipolar/bipolar depression; unilateral electrode placement; information on pulse width; EQ-5D measurements before and after ECT. Multiple linear regressions were performed to investigate the association between pulse width (<0.5 ms; 0.5 ms; >0.5 ms) and HRQoL (EQ-5D-3L index; EQ VAS) one week after ECT (primary outcome) and six months after ECT (secondary outcome).

    RESULTS: The sample included 5,046 patients with unipolar (82%) or bipolar (18%) depression. At first ECT session, 741 patients (14.7%) had pulse width <0.5 ms, 3,639 (72.1%) had 0.5 ms, and 666 (13.2%) had >0.5 ms. There were no statistically significant associations between pulse width and HRQoL one week after ECT. In the subsample of patients with an EQ-5D index recorded six months after ECT (n = 730), patients receiving 0.5 ms had significantly lower HRQoL (-0.089) compared to <0.5 ms, after adjusting for demographic and clinical characteristics (p = .011). The corresponding analysis for EQ VAS did not show any statistically significant associations.

    CONCLUSION: No robust associations were observed between pulse width and HRQoL after ECT. On average, significant improvements in HRQoL were observed one week and six months after ECT for patients with unipolar or bipolar disease, independent of the pulse width received.

  • 18.
    Göterfelt, Linda
    et al.
    University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro.
    Ekman, Carl Johan
    Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden.
    Hammar, Åsa
    Department of Biological and Medical Psychology, University of Bergen; Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.
    Landén, Mikael
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
    Lundberg, Johan
    Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden.
    Nordanskog, Pia
    Center for Social and Affective Neuroscience, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden; Department of Psychiatry, Region Östergötland, Linköping, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    The Incidence of Dental Fracturing in Electroconvulsive Therapy in Sweden2020In: Journal of ECT, ISSN 1095-0680, E-ISSN 1533-4112, Vol. 36, no 3, p. 168-171Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: One adverse effect of electroconvulsive therapy (ECT) is dental fracture; thus, a bite guard and muscle relaxants are used to prevent it. Earlier research reported varying rates of dental fracture, but there is no large-scale study on the incidence of dental fracture during ECT. This study aimed to examine the incidence of dental fracture during ECT and to investigate whether the incidence differs between different sexes, age groups, diagnosis groups, electrode placements, or number of treatment sessions.

    METHODS: This register-based study used data from the Swedish national quality register for ECT. All hospitals offering ECT report to this register, and the coverage ratio is about 90%. All registered patients who started an ECT series between January 2012 and January 2019 were included in this study, with the data representing 16,681 individuals, 38,862 series, and 254,906 sessions.

    RESULTS: Forty-six dental fractures were identified, giving an incidence of dental fracture of 0.2% per series, 0.02% per session, and 0.3% per individual. We did not find any significant associations between dental fracture rates and male or female populations, age, or different diagnosis groups, nor was there any significant difference between dental fracture rates and electrode placement. The mean number of treatments was significantly higher in the dental fracture group than in patients without dental fracture.

    CONCLUSIONS: There is a minimal risk of dental fracture during ECT. Our findings, together with those of other studies, provide further motivation for the use of a bite guard and muscle relaxant.

  • 19.
    Göteson, Andreas
    et al.
    Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.
    Clements, Caitlin C.
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Laboratories of Cognitive Neuroscience, Boston Children's Hospital, Boston, Massachusetts.
    Juréus, Anders
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Joas, Erik
    Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.
    Holmén Larsson, Jessica
    Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.
    Karlsson, Robert
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences.
    Pålsson, Erik
    Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.
    Landén, Mikael
    Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Alterations in the Serum Proteome Following Electroconvulsive Therapy for a Major Depressive Episode: A Longitudinal Multicenter Study2023In: Biological psychiatry global open science, E-ISSN 2667-1743, Vol. 3, no 4, p. 884-892Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Electroconvulsive therapy (ECT) is the most effective treatment for severe depression, but the biological changes induced by ECT remain poorly understood.

    METHODS: This study investigated alterations in blood serum proteins in 309 patients receiving ECT for a major depressive episode. We analyzed 201 proteins in samples collected at 3 time points (T): just before the first ECT treatment session (T0), within 30 minutes after the first ECT session (T1), and just before the sixth ECT session (T2).

    RESULTS: Using statistical models to account for repeated sampling, we identified 152 and 70 significantly (<5% false discovery rate) altered proteins at T1 and T2, respectively. The most pronounced alterations at T1 were transiently increased levels of prolactin, myoglobin, and kallikrein-6. However, most proteins had decreased levels at T1, with the largest effects observed for pro-epidermal growth factor, proto-oncogene tyrosine-protein kinase Src, tumor necrosis factor ligand superfamily member 14, sulfotransferase 1A1, early activation antigen CD69, and CD40 ligand. The change of several acutely altered proteins correlated with electric current and pulse frequency in a dose-response-like manner. Over a 5-session course of ECT, some acutely altered levels were sustained while others increased, e.g., serine protease 8 and chitinase-3-like protein 1. None of the studied protein biomarkers were associated with clinical response to ECT.

    CONCLUSIONS: We report experimental data on alterations in the circulating proteome triggered by ECT in a clinical setting. The findings implicate hormonal signaling, immune response, apoptotic processes, and more. None of the findings were associated with clinical response to ECT.

  • 20.
    Güney, Pelin
    et al.
    niversity Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro.
    Ekman, Carl Johan
    Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Region Stockholm, Stockholm, Sweden.
    Hammar, Åsa
    Department of Biological and Medical Psychology, University of Bergen; Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.
    Heintz, Emelie
    Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
    Landén, Mikael
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg.
    Lundberg, Johan
    Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Region Stockholm, Stockholm, Sweden.
    Nordanskog, Pia
    Center for Social and Affective Neuroscience, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden; Department of Psychiatry, Region Östergötland, Linköping, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Electroconvulsive Therapy in Depression: Improvement in Quality of Life Depending on Age and Sex2020In: Journal of ECT, ISSN 1095-0680, E-ISSN 1533-4112, Vol. 36, no 4, p. 242-246Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: It is uncertain if there are variations in the improvement of quality in life between sexes and age groups after electroconvulsive therapy (ECT). The aim of this study was to investigate how health-related quality of life changed after treatment and to examine differences in the results between sex and age groups.

    METHODS: This register-based study used data from the Swedish national quality register for ECT. The study population was patients diagnosed with depression who had received ECT. Health-related quality of life was quantified using the 3-level version the EuroQol 5-dimensional questionnaire (EQ-5D 3 L). Analysis of variance was used to compare change in EQ-5D score from pretreatment to posttreatment between sex and age groups.

    RESULTS: There was a statistically significant improvement in EQ-5D index score and EQ visual analog scale (VAS) score in all patient groups after ECT. The mean improvement in EQ-5D index score and EQ-VAS score ranged from 0.31 to 0.46 and 28.29 to 39.79, respectively. Elderly patients had greater improvement in EQ-5D index score and EQ-VAS score than younger patients. There was no significant difference in improvement between the sexes. The mean improvement in EQ-5D index score was 0.40 for male patients and 0.41 for female patients.

    CONCLUSIONS: Electroconvulsive therapy had a considerable effect on health-related quality of life in patients with depression of both sexes and all age groups. The improvement was greatest in elderly patients, who more often had psychotic features. More studies are needed to investigate the long-term effects of ECT and to further explain the varying treatment results between elderly and younger patients.

  • 21.
    Holländare, Fredrik
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Tillfors, Maria
    Department of Social and Psychological Studies, Karlstad University, Karlstad, Sweden; Centre for Health and Medical Psychology, Örebro University, Örebro, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Sellin, Tabita
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Are quantity and content of psychiatric interventions associated with suicide? A case-control study of a Swedish sample2020In: BMC Psychiatry, E-ISSN 1471-244X, Vol. 20, no 1, article id 13Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Research is required to identify those psychiatric interventions with a protective effect against suicide. The overarching aim of the current study was to examine whether completed suicide in psychiatric patients in a Swedish population was associated with the quantity and nature of previous medical and psychosocial treatment interventions.

    METHODS: This retrospective case-control study (n = 308) compared a group of deceased psychiatric patients with matched controls. For every case of suicide, a control was found within psychiatry that matched according to sex, age, and primary psychiatric diagnosis. A stepwise forward logistic regression model with suicide as the dependent outcome variable was used.

    RESULTS: Receiving pharmacotherapy combined with psychotherapy [OR: 0.44 (95% CI: 0.226-0.876), p = 0.019] and a higher number of outpatient visits in psychiatry [OR: 0.99 (95% CI: 0.982-0.999), p = 0.028] were negatively associated with suicide. These associations were still significant after controlling for previous serious suicide attempts and somatic comorbidity.

    CONCLUSIONS: Frequent visits and pharmacotherapy combined with psychotherapy seem to be important for preventing suicide in psychiatric patients. The reasons for not receiving such therapy are important issues for further study.

  • 22.
    Holm, Jonas
    et al.
    School of Medical Sciences, Örebro University, Örebro, Sweden .
    Brus, Ole
    Örebro University, School of Medical Sciences. Örebro University Hospital, Örebro, Sweden.
    Båve, Ullvi
    Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Landen, Mikael
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
    Lundberg, Johan
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Nordanskog, Pia
    Center for Social and Affective Neuroscience, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden; Department of Psychiatry, Region Östergötland, Linköping, Sweden.
    von Knorring, Lars
    Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden .
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences.
    Improvement of cycloid psychosis following electroconvulsive therapy2017In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 71, no 6, p. 405-410Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The treatment of choice for cycloid psychosis has traditionally been electroconvulsive therapy (ECT), but there is a lack of studies on its effectiveness.

    AIMS: The primary aim of this register study was to determine the rates of remission and response after ECT for cycloid psychosis. The secondary aim was to examine possible predictors of outcome.

    METHODS: Data were obtained from the National Quality Register for ECT in Sweden. The study population was patients (n = 42) who received ECT for acute polymorphic psychotic disorder without symptoms of schizophrenia or for cycloid psychosis between 2011-2015 in 13 hospitals. Remission and response rates were calculated using Clinical Global Impression-Severity (CGI-S) and -Improvement scores, respectively. Variables with possible predictive value were tested using Chi-square and Fisher's exact test.

    RESULTS: The response rate was 90.5%. The remission rate was 45.2%. Of 42 patients, 40 improved their CGI-S score after ECT (p < 0.001). The mean number of ECT treatments was 2.5 for non-responders and 7.0 for responders (p = 0.010). The mean number of ECT treatments did not differ significantly between remitters and non-remitters (7.2 vs 6.1, p = 0.31). None of the other investigated potential predictors was statistically significantly associated with outcome.

    CONCLUSIONS: ECT is an effective treatment for cycloid psychosis. Future studies need to compare the outcome of ECT to that of other treatment strategies.

    CLINICAL IMPLICATIONS: The high response rate with ECT indicates that cycloid psychosis is a clinically useful diagnosis.

  • 23.
    Kalling, Styrbjörn
    et al.
    Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden.
    Brus, Ole
    Örebro University, School of Medical Sciences.
    Landén, Mikael
    Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Lundberg, Johan
    Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet and Region Stockholm, Stockholm, Sweden.
    Nordanskog, Pia
    Department of Clinical and Experimental Medicine, Center for Social and Affective Neuroscience, Faculty of Health Sciences, Linköping University, Linköping, Sweden; Department of Psychiatry, Region Östergötland, Linköping, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Relapse risk after in-ward electroconvulsive therapy for acute polymorphic psychotic disorder2021In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 75, no 3, p. 201-206Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Acute polymorphic psychotic disorder (APPD) without symptoms of schizophrenia is a serious psychiatric condition. APPD can be effectively treated with electroconvulsive therapy (ECT), but little is known about relapse prevention after ECT for APPD.

    MATERIALS AND METHODS: This was a retrospective register-based study conducted with 97 patients with APPD (ICD-10 diagnosis F23.0). We estimated the rates of readmission and suicide, and the prognostic factors of these outcomes after ECT. We combined data from several national Swedish registers and used Cox's regression analysis to identify demographic factors, disease characteristics, and relapse preventive treatments that predicted time to readmission or suicide (relapse). Data registered between 2011 and 2016 were used in the study.

    RESULTS: Twenty percent of cases relapsed within a year. Thereafter, relapse rate was low. Two cases died during follow-up, whereof one by suicide. Anxiolytic treatment, lamotrigine treatment, and having more than four previous psychiatric hospital admissions were associated with shorter time to relapse. The most robust of these associations was between anxiolytics and relapse risk.

    CONCLUSIONS: The first year after discharge from APPD is the period associated with the highest risk of relapse. Having many previous admissions was associated to relapse risk after ECT for APPD. The associations between anxiolytics, lamotrigine, and relapse are uncertain and might be influenced by indication bias.

  • 24.
    Kellner, Charles H.
    et al.
    New York Community Hospital, Brooklyn, NY, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    "Treatment Resistance" in Electroconvulsive Therapy (ECT) Patients: Time to Move On2019In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 140, no 5, p. 490-491Article in journal (Refereed)
    Abstract [en]

    The concept of "treatment resistance" has become all the rage in depression research. It is used to define populations in research studies and in treatment algorithms as a rationale for moving on from standard antidepressants to other therapies. In such algorithms, electroconvulsive therapy (ECT) is often bundled improperly with less effective neurostimulation-methods and experimental pharmacotherapies.

  • 25.
    Kronsell, Alexander
    et al.
    Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences.
    Bell, Max
    Department of Anaesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital, Sweden; and Department of Physiology and Pharmacology, Karolinska Institutet, Sweden.
    Amin, Ridwanul
    Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Sweden.
    Mittendorfer-Rutz, Ellenor
    Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Sweden.
    Tiger, Mikael
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; and Stockholm Health Care Services, Region Stockholm, Sweden.
    The effect of anaesthetic dose on response and remission in electroconvulsive therapy for major depressive disorder: nationwide register-based cohort study2021In: BJPsych Open, E-ISSN 2056-4724, Vol. 7, no 2, article id e71Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Electroconvulsive therapy (ECT) is a safe and effective treatment for major depressive disorder (MDD). ECT treatment effect relies on induced generalised seizures. Most anaesthetics raise the seizure threshold and shorten seizure duration. There are no conclusive studies on the effect of anaesthetic dose on response and remission rates with ECT for MDD.

    AIMS: We aimed to examine the effect of different dose intervals of anaesthetics on response and remission after ECT for MDD.

    METHOD: We conducted a nationwide cohort study, using data from Swedish registers. Low-, medium- and high-dose intervals, adjusted for age and gender, were constructed for each anaesthetic drug. Response and remission were measured with the Clinical Global Impression - Severity and Improvement scales (CGI-I and CGI-S), and a self-rated version of the Montgomery-Åsberg Depression Rating Scale (MADRS-S). Logistic regression models were used to calculate adjusted odds ratios for response and remission rates.

    RESULTS: The study included 7917 patients who received ECT for MDD during 2012-2018. Patients were given either thiopental (64.1%) or propofol (35.9%). Low-dose intervals of anaesthetics were associated with increased rates of response (CGI-I: odds ratio 1.22, 95% CI 1.07-1.40, P = 0.004; MADRS-S: odds ratio 1.31, 95% CI 1.09-1.56, P = 0.004) and remission (CGI-S: odds ratio 1.37, 95% CI 1.17-1.60, P ≤ 0.001; MADRS-S: odds ratio 1.31, 95% CI 1.10-1.54, P = 0.002).

    CONCLUSIONS: We found improved treatment outcomes with low- compared with high-dose anaesthetic during ECT for MDD. To enhance treatment effect, deep anaesthesia during ECT for MDD should be avoided.

  • 26.
    Kronsell, Alexander
    et al.
    Psykiatri Nordväst, Stockholm County Council. Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, stockholm, Sweden; Stockholm Health Care Services, Stockholm County Council. Centrum för psykiatriforskning, Stockholm, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences.
    Tiger, Mikael
    Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden.
    Less memory complaints with reduced stimulus dose during electroconvulsive therapy for depression2019In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 259, p. 296-301Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Electroconvulsive therapy (ECT) is an effective treatment for depression, but there is risk of cognitive adverse events. This risk has been partially attributed to electrical charge, thus the optimal electrical stimulus dose is still under discussion. The aim of this study was to evaluate how the risk of subjective memory worsening was changed after lowering stimulus dose during ECT for patients with major depression.

    METHOD: A retrospective register-based intervention study of the effects of reduced electrical charges for patients receiving ECT for depression was conducted. The primary outcome was subjective memory worsening and the secondary outcome change in effect on depressive symptoms.

    RESULTS: A total of 154 patients were enrolled in the study (High dosage group: n = 57; Lower dosage group: n = 97). Subjective memory worsening after ECT occurred in 44% of patients in the high dosage group and in 25% of patients in the lower dosage group(p = 0.014). There was no significant between-group difference in the anti-depressive effect of ECT.

    LIMITATIONS: The study was register-based and the two groups were not randomized. A large portion of patients were initially excluded due to missing data in the register. The study lacks a long-term follow up.

    CONCLUSION: After implementing a change of treatment protocol, that lowered ECT stimulus doses from high to moderate, the occurrence of subjective memory worsening was significantly reduced without compromising treatment results.

  • 27.
    Lambrichts, Simon
    et al.
    KU Leuven, Department of Neurosciences, Research Group Psychiatry, Neuropsychiatry, Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center KU Leuven (UPC KU Leuven), Kortenberg, Belgium.
    Detraux, Johan
    KU Leuven, Department of Neurosciences, Research Group Psychiatry, University Psychiatric Center KU Leuven (UPC KU Leuven), Belgium.
    Vansteelandt, Kristof
    KU Leuven, Department of Neurosciences, Research Group Psychiatry, Neuropsychiatry, Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center KU Leuven (UPC KU Leuven), Kortenberg, Belgium.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Obbels, Jasmien
    KU Leuven, Department of Neurosciences, Research Group Psychiatry, Neuropsychiatry, Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center KU Leuven (UPC KU Leuven), Kortenberg, Belgium.
    Schrijvers, Didier
    Antwerp, Collaborative Antwerp Psychiatric Research Institute (CAPRI), Wilrijk, Belgium .
    Sienaert, Pascal
    KU Leuven, Department of Neurosciences, Research Group Psychiatry, Neuropsychiatry, Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center KU Leuven (UPC KU Leuven), Kortenberg, Belgium.
    Does lithium prevent relapse following successful electroconvulsive therapy for major depression? A systematic review and meta-analysis2021In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 143, no 4, p. 294-306Article, review/survey (Refereed)
    Abstract [en]

    OBJECTIVE: The risk of relapse following successful antidepressant treatment, including electroconvulsive therapy (ECT), is substantial. Lithium has been suggested to effectively prevent relapse, yet data remain limited and inconclusive. We performed a systematic review and meta-analysis to examine the efficacy of continuation treatment with lithium in preventing relapse following a successful acute course of ECT in patients with major depression, in comparison to continuation treatment without lithium. We also assessed the role of several study characteristics, possibly impacting the treatment effect.

    METHODS: A systematic literature search, using the PubMed, Embase, Web of Science and Cochrane Library databases (up to June 2020), was conducted for prospective and retrospective studies, including patients with unipolar or bipolar depression, that assessed the efficacy of lithium for post-ECT depressive relapse prevention.

    RESULTS: Of 2556 records screened, 14 articles reporting on 9748 participants who received continuation treatment either with (N=1571) or without lithium (N=8177) were included in the meta-analysis. Patients receiving lithium were less likely to experience depressive relapse after a successful acute course of ECT, compared to patients receiving post-ECT prophylaxis without lithium (weighted odds ratio (OR)=0.53, 95% confidence interval (CI)=0.34, 0.82), with a number needed to treat (NNT) of 7 (95% CI=4, 21). We found some limited evidence that older patients may benefit more from continuation treatment with lithium, compared to younger patients. Using the GRADE criteria, the quality of evidence for our outcome measure (i.e., relapse rate) was rated as very low.

    CONCLUSION: Continuation treatment with lithium may have superior efficacy in reducing the risk of relapse after a successful acute ECT course for major depression, in comparison to continuation treatment without lithium. High-quality studies are needed to confirm this finding.

  • 28.
    Lindblad, L.
    et al.
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Sweden.
    Otterbeck, A.
    Anesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Nordenskjöld, Anna M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiology.
    Risk factors for mortality of medical causes within 30 days of electroconvulsive therapy2023In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 320, p. 527-533Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Electroconvulsive therapy (ECT) is used to treat severe psychiatric disorders and is associated with reduced risk of suicide and all-cause mortality in patients with severe depression. We investigated the causes of death occurring shortly after ECT and identified potential risk factors for medical causes of death.

    METHODS: Patients treated with ECT between 2012 and 2018 were included in this Swedish register-based study. Multivariate binary logistic regression was used to calculate odds ratios for covariates to determine potential predictors of 30-day mortality.

    RESULTS: Of the 20,225 included patients, 93 (0.46 %) died of suicide and 123 (0.61 %) died of medical causes after ECT. Cardiovascular disease was the most common medical cause of death (n = 49, 40 %). An older age, a Charlson Comorbidity Index of 1 or more, atrial fibrillation, kidney disease, reflux disease, dementia, and cancer were associated with increased risk of death by medical causes.

    LIMITATIONS: Real-life observational studies based on registry data may demonstrate associations, but cannot determine causality. If medical records had been available, we would be better able to determine if deaths were due to the ECT, anesthesia, pre-existing medical conditions, or the mental disorder.

    CONCLUSIONS: ECT appears to be a low-risk medical procedure. Older individuals with severe somatic diseases have the highest risk of death and extra measures should be considered to optimize their medical health during the pre-ECT workup, and during and after ECT.

  • 29.
    Midhage, Robin
    et al.
    Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.
    Hermansson, Liselotte
    Örebro University, School of Health Sciences. University Health Care Research Center.
    Söderberg, Per
    Department of Psychiatric Research and Development, Säter, Sweden.
    Tungström, Stefan
    Department of Psychiatric Research and Development, Säter, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Center.
    Svanborg, Cecilia
    Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden.
    Ginsberg, Ylva
    Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden; The National Board of Health and Welfare, Stockholm, Sweden.
    Ramklint, Mia
    Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.
    Psychometric evaluation of the Swedish self-rated 36-item version of WHODAS 2.0 for use in psychiatric populations: using classical test theory2021In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 75, no 7, p. 494-501Article in journal (Refereed)
    Abstract [en]

    AIM: The aim of this study was to evaluate the reliability and validity of the Swedish version of the self-rated 36-item WHODAS 2.0 in patients from Swedish psychiatric outpatient settings, using classical test theory.

    METHODS: The 36-item WHODAS 2.0, together with the Sheehan Disability Scale (SDS), was filled in by a sample of 780 participating psychiatric patients: 512 (65.6%) women, 263 (33.7%) men, and 5 (0.6%) who did not report any sex.

    RESULTS: The internal consistency, measured by Cronbach's alpha, for the different domains of functioning were between 0.70 and 0.94, and interpreted as good. The confirmatory factor analysis (CFA) revealed two levels: the first level consisted of a general disability factor, while the second level consisted of the six domains of the scale, respectively. The model had borderline fit. There was a significant correlation between WHODAS 2.0 36-item and SDS (n = 395). The WHODAS 2.0 differed significantly between diagnostic groups.

    CONCLUSION: The present study demonstrates that the Swedish self-rated 36-item version of WHODAS 2.0, within a psychiatric outpatient population, showed good reliability and convergent validity. We conclude that the self-rated 36-item Swedish version of WHODAS 2.0 can be used for valid interpretations of disability in patients with psychiatric health conditions.

  • 30.
    Movahed, Pouya
    et al.
    Lund University, Lund, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences.
    Kellner, Charles H
    Medical University of South Carolina, Charleston, SC, USA.
    Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression2023In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 389, no 10, p. 960-961Article in journal (Refereed)
  • 31.
    Nordanskog, Pia
    et al.
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Hultén, Martin
    Dept of Clinical Sciences Lund, Psychiatric Neuromodulation Unit (PNU), Faculty of Medicine, Lund University, Lund, Sweden.
    Landén, Mikael
    Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
    Lundberg, Johan
    Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Section for Affective Disorders, Northern Stockholm Psychiatry, Stockholm, Sweden.
    von Knorring, Lars
    Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Psychiatry, Örebro University Hospital, Örebro, Sweden.
    Electroconvulsive Therapy in Sweden 2013: Data From the National Quality Register for ECT2015In: Journal of ECT, ISSN 1095-0680, E-ISSN 1533-4112, Vol. 31, no 4, p. 263-267Article in journal (Refereed)
    Abstract [en]

    Objectives: The use of electroconvulsive therapy (ECT) varies across countries. The aim of this study was to describe and explore the use of ECT in Sweden in 2013.

    Methods: The Swedish mandatory patient register of the National Board of Health and Welfare includes information on diagnoses and treatments, including ECT. All 56 hospitals that provide ECT in Sweden also report to the nonmandatory national quality register for ECT, which contains information on patient and treatment characteristics. In this study, we combined data from both registers. In addition, all hospitals responded to a survey concerning equipment and organization of ECT.

    Results: We identified 3972 unique patients who received ECT in Sweden in 2013. This translates into 41 ECT-treated individuals per 100,000 inhabitants. Of these patients, 85% opted to participate in the quality register. The median age was 55 years (range, 15-94 years), and 63% were women. The indication was depression in 78% of the treatment series. Of 4 711 hospitalized patients with severe depression, 38% received ECT. The median number of treatments per index series was 7. Unilateral treatment was used in 86% of the series.

    Conclusions: In Sweden, ECT is used at a relatively high rate as compared with other western countries, and the rate was unchanged from the last survey in 1975. However, there is room for improvement in the specificity of use and availability of ECT for disorders where ECT is considered a first-line treatment.

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  • 32.
    Nordenskjöld, Axel
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    ECT is superior to pharmacotherapy for the short-term treatment of medication-resistant inpatients with bipolar depression2015In: Evidence-Based Mental Health, ISSN 1362-0347, E-ISSN 1468-960X, Vol. 18, no 4, p. 118-118Article in journal (Refereed)
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  • 33.
    Nordenskjöld, Axel
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Electroconvulsive therapy for depression2013Doctoral 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.

    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, 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: 2024-01-17Bibliographically 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)2-s2.0-84867142401 (Scopus ID)
    Available from: 2013-02-15 Created: 2013-02-15 Last updated: 2023-12-08Bibliographically 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
    Psychiatry
    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: 2022-02-11Bibliographically 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: 2023-07-04Bibliographically 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: 2022-02-11Bibliographically approved
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  • 34.
    Nordenskjöld, Axel
    et al.
    Örebro University, School of Medical Sciences. The University Health Care Research Centre.
    Güney, Pelin
    The University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Nordenskjöld, Anna M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiology.
    Major adverse cardiovascular events following electroconvulsive therapy in depression: A register-based nationwide Swedish cohort study with 1-year follow-up2022In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 296, p. 298-304Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The cardiovascular response during electroconvulsive therapy (ECT) could induce major adverse cardiovascular events (MACE) in the short-term, while reduced depression could decrease the risk of MACE in the long-term. The balance between these potential effects has not been thoroughly investigated.

    METHODS: This nationwide, registry-based cohort study included all patients admitted to Swedish hospitals due to moderate or severe unipolar depression between 2011 and 2018. Patients were divided into an ECT group and a non-ECT group, and followed for 1 year. Patients were matched by risk factors for cardiovascular disease by propensity score matching. Cox regression was used to examine the association between ECT and MACE.

    RESULTS: Out of a total of 28 584 inpatients, 5476 patients who had received ECT were matched to 5476 non-ECT patients. ECT was associated with reduced risk of MACE within 90 days and 1 year. Within 1 year after admission, a total of 127 patients (2.3%) in the non-ECT group and 82 patients (1.4%) in the ECT group had at least one MACE (hazard ratio [HR], 0.65; 95% confidence interval, 0.49-0.85).

    LIMITATIONS: Real-life observational studies carry risk for residual confounding.

    CONCLUSIONS: ECT in patients hospitalized for depression was not associated with any significant short-term risks of cardiovascular events. Instead, ECT was associated with a reduced risk of MACE within 1 year after admission compared with patients not treated with ECT. This association may be explained by reduced depressive symptoms after ECT, improved risk factor management in the ECT-group or by residual confounding by indication.

  • 35. Nordenskjöld, Axel
    et al.
    Knorring, Lars von
    Engström, Ingemar
    Örebro University, School of Health and Medical Sciences.
    Rehospitalization rate after continued electroconvulsive therapy: a retrospective chart review of patients with severe depression2011In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 65, no 1, p. 26-31Article in journal (Refereed)
    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.

  • 36.
    Nordenskjöld, Axel
    et al.
    Örebro University, School of Medical Sciences. Universitetssjukhuset Örebro, Örebro.
    Movahed, Pouya
    Skånes universitetssjukhus, Lund; Lunds universitet, Lund.
    Vi förutspår ingen revolution inom depressionssjukvården2023In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 120, no 46-47, article id 23149Article in journal (Refereed)
  • 37.
    Nordenskjöld, Axel
    et al.
    Örebro University, School of Medical Sciences. Department of Psychiatry, Örebro University Hospital, Örebro, Sweden.
    Mårtensson, Björn
    Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Pettersson, Agneta
    Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), Stockholm, Sweden; Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
    Heintz, Emelie
    Health Economist, Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), Stockholm, Sweden; Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
    Landén, Mikael
    Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Effects of Hesel-coil deep transcranial magnetic stimulation for depression: a systematic review2016In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 70, no 7, p. 492-497Article, review/survey (Refereed)
    Abstract [en]

    Background: One third of the depressed patients are not improved by antidepressant drugs and psychological treatments, and there is a need for additional treatments. Repetitive transcranial magnetic stimulation (rTMS) is being developed towards an alternative in treatment-resistant depression. Deep transcranial stimulation (dTMS) with the Hesel-coil (H-coil) is a further development of rTMS aiming to enhance the effect by getting the magnetic pulses to penetrate deeper into the brain.

    Aims: This report aims to assess the evidence-base for dTMS for depression. The report also includes an assessment of the ethical and economic aspects involved.

    Methods: A systematic review of the effects of H-coil dTMS on depression was conducted and the scientific support was evaluated using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

    Results: Only one controlled study was identified. In the sham-controlled randomized study, 212 participants with major depression that had not responded to antidepressant medication were enrolled. A two-point superiority in Hamilton Depression Rating Scale was observed in the dTMS arm vs the sham-arm at 4 weeks, but the difference was not statistically significant. No serious adverse events were reported apart from rare cases of epileptic seizures.

    Conclusions: The existing scientific support for H-coil dTMS therapy for depression is insufficient. The clinical implication is that the use of dTMS in depression should be restricted to the framework of clinical trials pending further studies. Fortunately, additional studies are underway and the evidence base should presumably improve over the next several years.

  • 38.
    Nordenskjöld, Axel
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Psychiatric Research Centre.
    von Knorring, Lars
    Psychiatric Research Centre, Örebro County Council, Örebro, Sweden; Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.
    Brus, Ole
    Örebro University Hospital, Örebro County Council, Örebro, Sweden.
    Engström, Ingemar
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital.
    Predictors of regained occupational functioning after electroconvulsive therapy (ECT) in patients with major depressive disorder: a population based cohort study2013In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 67, no 5, p. 326-333Article in journal (Refereed)
    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.

  • 39.
    Nordenskjöld, Axel
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Psychiatry, University Hospital Örebro, Örebro County, Örebro, Sweden.
    von Knorring, Lars
    Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden; Psychiatric Research Centre, School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Engström, Ingemar
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Predictors of the short-term responder rate of Electroconvulsive therapy in depressive disorders: a population based study2012In: BMC Psychiatry, E-ISSN 1471-244X, Vol. 12, article id 115Article in journal (Refereed)
    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.

  • 40.
    Nordenskjöld, Axel
    et al.
    Örebro University, School of Health and Medical Sciences.
    von Knorring, Lars
    Engström, Ingemar
    Örebro University, School of Health and Medical Sciences.
    Predictors of time to relapse/recurrence after electroconvulsive therapy in patients with major depressive disorder: a population-based cohort study2011In: Depression Research and Treatment, ISSN 2090-1321, E-ISSN 2090-133X, Vol. 2011, p. 470985-Article in journal (Refereed)
    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.

  • 41.
    Nordenskjöld, Axel
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital.
    von Knorring, Lars
    Psychiatry Research Center, Örebro City Council, Örebro, Sweden.
    Ljung, Tomas
    Psychiatry Clinic, Falun Hospital, Falun, Sweden.
    Carlborg, Andreas
    Dept Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden; Danderyd Hospital, Stockholm, Sweden .
    Brus, Ole
    Psychiatry Research Center, Örebro City Council, Örebro, Sweden.
    Engström, Ingemar
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital.
    Continuation electroconvulsive therapy with pharmacotherapy versus pharmacotherapy alone for prevention of relapse of depression: A Randomized Controlled Trial2013In: Journal of ECT, ISSN 1095-0680, E-ISSN 1533-4112, Vol. 29, no 2, p. 86-92Article in journal (Refereed)
    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.

  • 42.
    Nygren, Adam
    et al.
    Karolinska Institutet, Stockholm, Sweden.
    Reutfors, Johan
    Center for Pharmacoepidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
    Brandt, Lena
    Center for Pharmacoepidemiology, Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institute, Stockholm, Sweden.
    Bodén, Robert
    Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. Health Care Research Center.
    Tiger, Mikael
    Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
    Response to electroconvulsive therapy in treatment resistant depression: A nationwide register-based study2022In: Pharmacoepidemiology and Drug Safety, ISSN 1053-8569, E-ISSN 1099-1557, Vol. 31, no Suppl. 2, p. 310-310Article in journal (Other academic)
    Abstract [en]

    Background: Electroconvulsive therapy (ECT) is often considered for patients with treatment resistant depression (TRD), as recommended by guidelines from several countries. However, previous studies have shown inconsistent results regarding the response to ECT in patients with TRD.

    Objectives: To assess and compare the response rate of ECT for patients with TRD to that of other patients with depression (i.e. non-TRD) in a large and clinically representative patient sample. We hypothesized that patients with TRD would have a lower ECTresponse rate than other patients with depression.

    Methods: Patients ≥18 years old, treated for a unipolar, non-psychotic depressive episode with at least one ECT session as part of a first-time, index ECT series between Jan. 1 2011 and Dec. 31 2017 were identified from the Swedish National Quality Register for ECT, and individually linked with other population-based registers. Patients with any life timediagnosis of bipolar disorder, manicor hypomanic episode, psychotic disorder, or dementia as well as those lacking registration of the primary out-come measure were excluded. Using the Prescribed Drug Register, we classified patients as having TRD if they had initiated a third consecutive trial of antidepressants or add-on medications before starting ECT. Remaining patients were considered to have other depression. The main outcome measure was response to ECT according to the Clinical Global Impressions–Improvement scale (CGI-I) assessed within a week after the ECT series, defined as a CGI-I assessment of ‘much' or ‘very much improved'. Outcome measures were compared between patients with TRD and with other depression using logistic regression to calculate odds ratios of response and corresponding confidence intervals, adjusting for potential confounders including sociodemographic and clinical covariates.

    Results: A total of 4244 patients were included. Of these, 1121 patients were classified as TRD (61.2% female, mean age 51.4 years) and 3123 (54.3 % female, mean age 50.4 years) patients had other depression. The CGI-I response rate after ECT among patients with TRD was 65.9% compared to 75.9% in other patients with depression (adjusted odds ratio 0.64 [95% CI 0.54–0.75]).

    Conclusions: A clear majority of patients with TRD as well as patients with other depression responded to ECT, although the response rate was lower in TRD.

  • 43.
    Nygren, Adam
    et al.
    Centre for Pharmacoepidemiology, Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Sweden.
    Reutfors, Johan
    Centre for Pharmacoepidemiology, Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Sweden.
    Brandt, Lena
    Centre for Pharmacoepidemiology, Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Sweden.
    Bodén, Robert
    Department of Medical Sciences, Psychiatry, Uppsala University, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Sweden.
    Tiger, Mikael
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Sweden.
    Response to electroconvulsive therapy in treatment-resistant depression: nationwide observational follow-up study2023In: BJPsych Open, E-ISSN 2056-4724, Vol. 9, no 2, article id e35Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Previous studies have not investigated response rates after electroconvulsive therapy (ECT) in patients with non-psychotic treatment-resistant depression (TRD).

    AIMS: To assess and compare the response rate of ECT for patients with TRD and non-TRD, in a large and clinically representative patient sample.

    METHOD: Patients aged ≥18 years, who were treated for a unipolar, non-psychotic depressive episode with at least one ECT session as part of a first-time, index ECT series between 1 January 2011 and 31 December 2017 were included from the Swedish National Quality Register for ECT. Patients who had initiated a third consecutive trial of antidepressants or add-on medications before start of ECT were classified as having TRD. Patients not meeting criteria for TRD were classified as non-TRD. The main outcome was response to ECT according to the Clinical Global Impressions - Improvement Scale (CGI-I), scored as 1 or 2 ('very much' or 'much improved' after ECT, respectively). Logistic regression was used to compare outcome measures between TRD and non-TRD, adjusting for potential confounders.

    RESULTS: A total of 4244 patients were included. Of these, 1121 patients had TRD and 3123 patients had non-TRD. The CGI-I response rate was 65.9% in the TRD group compared with 75.9% in the non-TRD group (adjusted odds ratio 0.64, 95% CI 0.54-0.75). Older age and more severe depression were predictors of response in patients with TRD.

    CONCLUSIONS: A clear majority of patients with TRD, as well as patients with non-TRD, responded to ECT, although the response rate was somewhat lower for TRD.

  • 44.
    Popiolek, Katarzyna
    et al.
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Bejerot, Susanne
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Brus, Ole
    Örebro University, School of Medical Sciences.
    Hammar, Åsa
    Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway: Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.
    Landén, Mikael
    Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Lundberg, Johan
    Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden; Stockholm County Council, Stockholm, Sweden.
    Nordanskog, Pia
    Center for Social and Affective Neuroscience, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden; Department of Psychiatry, Region Östergötland, Linköping, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Electroconvulsive therapy in bipolar depression: effectiveness and prognostic factors2019In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 140, no 3, p. 196-204Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Electroconvulsive therapy (ECT) is used in patients with severe forms of bipolar depression. ECT is effective but not all patients respond. The aim of this study was to determine prognostic factors for response to ECT in patients hospitalized for bipolar depression.

    METHODS: Data were obtained from several national Swedish registers. All patients with bipolar depression treated with ECT in any hospital in Sweden between 2011 and 2016 for whom information about ECT response was available were included (n = 1251). Response was defined as a score on the Clinical Global Impression - Improvement scale of one or two. Univariate and multivariate logistic regression were conducted to investigate associations between socio-demographic and clinical factors and response.

    RESULTS: Response was achieved in 80.2% patients. Older age was associated with higher response rate to ECT. Patients with comorbid obsessive-compulsive disorder or personality disorder, and patients previously treated with lamotrigine had lower response rate.

    CONCLUSION: ECT for bipolar depression was associated with very high response rates. The strongest prognostic factors were higher age, absence of comorbid obsessive-compulsive disorder or personality disorder, and less prior pharmacologic treatment.

  • 45.
    Popiolek, Katarzyna
    et al.
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Bejerot, Susanne
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Landén, Mikael
    Institute of Neuroscience and Physiology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Association of Clinical and Demographic Characteristics With Response to Electroconvulsive Therapy in Mania2022In: JAMA Network Open, E-ISSN 2574-3805, Vol. 5, no 6, article id e2218330Article in journal (Refereed)
    Abstract [en]

    Importance: Knowledge of the effectiveness of electroconvulsive therapy (ECT) in the treatment of manic episodes is based on clinical experience, but empirical evidence is scarce. Moreover, prognostic factors associated with response to ECT in patients with mania are poorly understood.

    Objective: To investigate the response to ECT in patients with manic episodes.

    Design, Setting, and Participants: This nationwide, register-based observational cohort study was conducted using data from patients admitted to psychiatric departments in Sweden that reported data to the Swedish National Quality Registry for ECT (Q-ECT). Patients admitted to any hospital in Sweden and receiving ECT for a manic episode between 2012 and 2019 were considered for inclusion (605 individuals). The outcome, Clinical Global Impression Improvement scale (CGI-I) score, was available in 571 patients. Data from several national registers were combined to determine clinical and sociodemographic factors. Analysis of data occurred from April through September 2021.

    Exposures: Patients treated with ECT for a mania were identified from the Q-ECT.

    Main Outcomes and Measures: Response to ECT was defined by a CGI-I score of 1 (very much improved) or 2 (much improved). Remission was defined as a Clinical Global Impression Severity scale (CGI-S) score of 1 (reference range or not ill) or 2 (minimally ill) within 1 week after ECT. Univariate and multivariable regression models were used to investigate associations of sociodemographic factors, psychopharmacology, and comorbidities with response.

    Results: Among 571 patients with mania treated with ECT (211 [37.0%] men; median [IQR] age, 46 [31-59] years), 482 patients (84.4%) responded to ECT. Comorbid anxiety and obsessive-compulsive disorder (OCD) were associated with lower odds of response to ECT (adjusted odds ratio [aOR], 0.48; 95% CI, 0.25-0.90 and aOR, 0.17; 95% CI, 0.06-0.56, respectively). Patients who were markedly ill (aOR, 2.93; 95% CI, 1.23-7.00), severely ill (aOR, 2.60; 95% CI, 1.06-6.34), or among the most extremely ill (aOR, 7.94; 95% CI, 2.16-29.21) according to CGI-S score had higher odds of response than those with mild or moderate illness.

    Conclusions and Relevance: This study found that ECT was associated with improvement for mania in clinical settings, with especially high response rates in patients with severe illness and those without comorbid anxiety or OCD.

  • 46.
    Popiolek, Katarzyna
    et al.
    Örebro University, School of Medical Sciences.
    Brus, Ole
    Örebro University, School of Medical Sciences.
    Elvin, Tove
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Landen, Mikael
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Institute of Neuroscience and Physiology, The Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
    Lundberg, Johan
    Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden; Stockholm County Council, Stockholm, Sweden.
    Nordanskog, Pia
    Center for Social and Affective Neuroscience, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden; Department of Psychiatry, Region Östergötland, Linköping, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Rehospitalization and suicide following electroconvulsive therapy for bipolar depression: A population-based register study2018In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 226, p. 146-154Article in journal (Refereed)
    Abstract [en]

    Background: Electroconvulsive therapy (ECT) is effective in bipolar depression, but relapse is common. The aim of the study was (i) to identify prognostic factors (ii) and to determine the impact of pharmacological approaches on the risk for rehospitalization or suicide.

    Methods: This register study analyzed data from individuals treated with inpatient ECT for bipolar depression. Subjects were identified using the Swedish National Patient Register between 2011 and 2014 and the Swedish National Quality Register for ECT. Other national registers provided data on psychopharmacotherapy, socio-demographic factors, and causes of death. The endpoint was the composite of rehospitalization for any psychiatric disorder, suicide attempt or completed suicide (RoS). Cox regression was used to calculate hazard ratios in univariate and multivariate models.

    Results: Data from 1255 patients were analyzed. The mean period of follow-up was 346 days.

    A total of 29%, 41%, and 52% of patients reached RoS at 3, 6, and 12 months post-discharge. A history of multiple psychiatric admissions, lower age, and post-discharge treatment with antipsychotics or benzodiazepines was associated with RoS.

    Limitations: Indication bias may have affected the results.

    Conclusions: A history of multiple hospital admissions and lower age are key predictors of the composite of rehospitalization or suicide in patients treated with ECT for bipolar depression. Lithium might be effective. By contrast, antipsychotics and benzodiazepines were associated with increased risk, but possibly this finding was influenced by indication bias.

  • 47.
    Pålsson, Erik
    et al.
    Psychiatry and Neurochemistry, University of Gothenburg, Göteborg, Sweden erik.palsson@gu.se.
    Melchior, Lydia
    Bipolarmottagning, Sahlgrenska University Hospital, Göteborg, Sweden.
    Lindwall Sundel, Kristina
    Bipolarmottagning, Sahlgrenska University Hospital, Göteborg, Sweden.
    Karanti, Alina
    Psychiatry and Neurochemistry, University of Gothenburg, Göteborg, Sweden.
    Joas, Erik
    Psychiatry and Neurochemistry, University of Gothenburg, Göteborg, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Centre, Faculty of Medicine and Health, Örebro Universitet, Örebro, Sweden.
    Agestam, Mattias
    Northern Stockholm Psychiatry, Stockholm, Sweden.
    Runeson, Bo
    Psychiatry, Karolinska Institute, Stockholm, Sweden.
    Landén, Mikael
    Psychiatry and Neurochemistry, University of Gothenburg, Göteborg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Cohort profile: the Swedish National Quality Register for bipolar disorder(BipoläR)2022In: BMJ Open, E-ISSN 2044-6055, Vol. 12, no 12, article id e064385Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The Swedish National Quality Register for bipolar affective disorder, BipoläR, was established in 2004 to provide nationwide indicators for quality assessment and development in the clinical care of individuals with bipolar spectrum disorder. An ancillary aim was to provide data for bipolar disorder research.

    PARTICIPANTS: Inclusion criteria for registration in BipoläR is a diagnosis of bipolar spectrum disorder (ICD codes: F25.0, F30.1-F30.2, F30.8-F31.9, F34.0) and treatment at an outpatient clinic in Sweden. BipoläR collects data from baseline and annual follow-up visits throughout Sweden. Data is collected using questionnaires administered by healthcare staff. The questions cover sociodemographic, diagnostic, treatment, outcomes and patient reported outcome variables. The register currently includes 39 583 individual patients with a total of 75 423 baseline and follow-up records.

    FINDINGS TO DATE: Data from BipoläR has been used in several peer-reviewed publications. Studies have provided knowledge on effectiveness, side effects and use of pharmacological and psychological treatment in bipolar disorder. In addition, findings on the diagnosis of bipolar disorder, risk factors for attempted and completed suicide and health economics have been reported. The Swedish Bipolar Collection project has contributed to a large number of published studies and provides important information on the genetic architecture of bipolar disorder, the impact of genetic variation on disease characteristics and treatment outcome.

    FUTURE PLANS: Data collection is ongoing with no fixed end date. Currently, approximately 5000 new registrations are added each year. Cohort data are available via a formalised request procedure from Centre of Registers Västra Götaland (e-mail: registercentrum@vgregion.se). Data requests for research purposes require an entity responsible for the research and an ethical approval.

  • 48.
    Ramklint, Mia
    et al.
    Department of Medical sciences, Child and Adolescent Psychiatry, Uppsala University, Uppsala, Sweden.
    Söderberg, Per
    Psychiatric Research and Development Department, Säter, Sweden.
    Tungström, Stefan
    Psychiatric Research and Development Department, Säter, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. University Health Care Research Center.
    Hermansson, Liselotte
    Örebro University, School of Health Sciences. University Health Care Research Center.
    Validity of the self-rated 36-item World Health Organization Disability Assessment Schedule (WHODAS) 2.0 as a measure of functioning in Swedish psychiatric outpatients2023In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 77, no 3, p. 276-281Article in journal (Refereed)
    Abstract [en]

    Purpose: The aim of this study was to investigate concurrent validity of the Swedish self-rated 36-item World Health Organization Disability Assessment Schedule (WHODAS) 2.0 by comparison with professional Global Assessment of Functioning (GAF) ratings in psychiatric outpatients.

    Material and methods: A cross-sectional convenience sample of 444 patients was recruited from their regular psychiatric outpatient settings. The patients filled out the WHODAS 2.0; their clinicians provided clinical information and performed GAF ratings blinded to the patients' assessments. Analyses of correlations, variance components, and ROC curves were performed to investigate the validity of the WHODAS 2.0 through comparison with the GAF. The variance component analyses included working status, psychosocial problems, number of diagnostic groups, and remission status. GAF ratings were separated as total (GAF-T), symptoms (GAF-S), and functioning (GAF-F).

    Results: There was significant correlation (p < 0.001) between WHODAS 2.0 total and domain scores and GAF-S, GAF-F, and GAF-T ratings. The correlations varied from r = 0.29 to r = 0.48, with the highest being between GAF-F rating and WHODAS 2.0 total score. Repeating the analyses for separate diagnostic groups replicated the findings, though not for psychotic, substance-related, and eating disorders. The WHODAS 2.0 showed good ability to distinguish impaired functioning below a fixed GAF-T cut-off of 70 (area under the curve: 0.74-0.78). The explained variance was lower for the WHODAS 2.0 than for the GAF (38.9% vs. 59.2%).

    Conclusions: Concurrent validity was found when comparing the Swedish self-administered 36-item version of WHODAS 2.0 with the expert-rated GAF in psychiatric outpatients.

  • 49.
    Rask, Olof
    et al.
    Division of Child and Adolescent Psychiatry, Department of Clinical Sciences, Lund University, Lund, Sweden; Child and Adolescent Psychiatry Emergency Unit, Cronquists gata 4g, 205 02, Malmö, Sweden. olof.rask@med.lu.se.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden.
    Johansson, Björn Axel
    Division of Child and Adolescent Psychiatry, Department of Clinical Sciences, Lund University, Lund, Sweden.
    Movahed Rad, Pouya
    Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
    Electroconvulsive therapy in children and adolescents: results from a population‑based study utilising the Swedish National Quality Register2023In: European Child and Adolescent Psychiatry, ISSN 1018-8827, E-ISSN 1435-165X, Vol. 32, no 11, p. 2649-2656Article in journal (Refereed)
    Abstract [en]

    Electroconvulsive therapy (ECT) is effective and safe for adults with severe depression, but less studied in adolescents. Here, we examined the indications, prevalence, practice, response and remission rates, and side effects in young people treated with ECT in Sweden. We also examined the usage of ECT in the transition to adult psychiatry. Using data from national patient registers and the Swedish National Quality Register for ECT (Q-ECT), we identified patients aged up to 19 years treated with ECT over a 5-year study period. Response and remission rates were analysed using the Clinical Global Impression (7-point scale)-Improvement (CGI-I) and Severity (CGI-S). A total of 118 individuals were identified, of which 105 were also enrolled in the Q-ECT. The most common indication for ECT was depression (68%; n = 80). Adolescents aged < 18 years were more severely ill before treatment than those aged 18 years (P < 0.01). Three of the hospitals in Sweden treated the majority of adolescents < 18 years old. The median number of sessions in each ECT series was seven. Unilateral placement of the electrodes was the most common (88%; n = 99). Fifty-seven percent (n = 54) of the patients responded (CGI-I, 1-2) to the treatment; remission (CGI-S, 1-2) was achieved by 32% (n = 30). Psychotic symptoms were associated with a higher response rate in patients with depression (P = 0.038). A deterioration of memory compared to pre-treatment was reported in six patients. ECT was associated with high response and remission rates in adolescents with severe psychiatric disorders after non-response to medication.

  • 50.
    Rundgren, Sara
    et al.
    School of Medical Sciences, University Health Care Research Centre, Örebro University, Örebro, Sweden.
    Brus, Ole
    Örebro University, School of Medical Sciences.
    Båve, Ullvi
    Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden.
    Landén, Mikael
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
    Lundberg, Johan
    Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden.
    Nordanskog, Pia
    Faculty of Health Sciences, Department of Clinical and Experimental Medicine, Center for Social and Affective Neuroscience, Linköping University, Linköping, Sweden; Department of Psychiatry, Region Östergötland, Linköping, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Improvement of postpartum depression and psychosis after electroconvulsive therapy: A population-based study with a matched comparison group2018In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 235, p. 258-264Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Electroconvulsive therapy (ECT) is used to treat postpartum depression and psychosis based on clinical experience and small observational studies.

    AIMS: The primary aim was to test the hypothesis that the response rate to ECT for depression and psychosis is higher during the postpartum period than outside this period. The secondary aim was to identify predictors of a response to ECT during the postpartum period.

    MATERIALS AND METHODS: Cases with postpartum depression and/or psychosis received ECT within 6 months of delivery. A matched comparison group with depression and/or psychosis (not within the postpartum period) was identified from the Swedish National Quality Register for ECT. The improvement 1 week after ECT was classified according to the Clinical Global Impressions Scale - Improvement scale (CGI-I) as responder (CGI-I score 1-2) or non-responder (CGI-I score 3-7).

    RESULTS: 185 cases and 185 comparison group subjects were included (46% with psychosis in each groups). More cases (87.0%) than comparison group subjects (73.5%) responded to ECT (p = 0.001). Adjusted binary regression analysis revealed that more severe symptoms prior to treatment were the only statistically significant predictor of response.

    LIMITATIONS: There was no control group without ECT treatment.

    CONCLUSION: The response rate of those with postpartum depression and/or psychosis to ECT was high. The response rate of patients with psychosis or depression was higher during the postpartum period than outside it. This study supports the use of ECT for severe forms of postpartum depression and/or psychosis.

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