To Örebro University

BACKGROUND: Data on clinical outcomes in psychotic depression remain limited. We examined hospitalization, suicide, and treatment patterns in Swedish patients with psychotic depression.

METHODS: This nationwide register-based study included patients with an index diagnosis of psychotic unipolar depression during 2012-2020. Post-index psychiatric hospitalizations and suicide deaths were examined descriptively and using logistic regression adjusted for sex, age, prior admissions, psychiatric comorbidity, index care setting (inpatient or outpatient), and pharmacological treatment. For patients treated with electroconvulsive therapy (ECT) during 2012-2020, the outcomes of response and remission according to the Clinical Global Impressions Scale were assessed by logistic regression.

RESULTS: Of 8048 patients, 54.8% were women, median age was 47 years (interquartile range 30-63), and 51.8% were diagnosed in specialized outpatient care. A total of 25.1% were hospitalized and 0.8% died by suicide within 36 weeks. Index diagnosis in inpatient care, prior admissions, comorbid alcohol or substance use disorder, antipsychotic treatment, and younger age (≤25 years) were associated with increased odds of post-index hospitalization. Younger age was associated with decreased odds of suicide. Among ECT-treated patients, 89.8% achieved response and 48.4% achieved remission. Younger age and prior admissions were associated with decreased odds of remission. Age 51-75 years, compared with ≤25 years, was associated with increased odds of response.

CONCLUSIONS: Psychotic depression carries a high risk of psychiatric hospitalization and suicide shortly after index diagnosis. Increased odds of hospitalization associated with antipsychotic treatment likely reflect confounding by indication. Among ECT-treated patients, response and remission rates were high.

BACKGROUND: Seizure duration during electroconvulsive therapy (ECT) correlates with treatment efficacy and may be influenced by depth of anaesthesia. The Patient State Index (PSi), derived from processed EEG, offers a potential method to monitor depth of anaesthesia during ECT. This study examined the correlation between pre-ictal PSi and EEG-seizure duration.

METHODS: In this prospective observational study, adult patients undergoing routine ECT at a Swedish university hospital were monitored using the SedLine pEEG system. Anaesthetic care followed standard protocols and the clinical team was blinded to PSi values. Pre-ictal PSi was defined as the final value prior to the ECT stimulus. EEG-seizure duration and relevant clinical variables were extracted from health records. The primary outcome was the association between pre-ictal PSi and EEG-seizure duration, analysed using a linear mixed-effects model adjusting for age and use of benzodiazepines or anticonvulsants. Secondary analyses explored sex and age effects on PSi over time and differences between baseline and pre-ictal PSi.

RESULTS: Eighty-seven ECT sessions in 37 patients were analysed. Median baseline PSi was 94 (IQR 4) and pre-ictal PSi was 38 (IQR 31; p < 0.001). No correlation was found between pre-ictal PSi and EEG-seizure duration. There were no significant effects of age or sex on pre-ictal PSi while there was a significant difference between sexes on baseline PSi. Artefact and EMG activity in the EEG signal were minimal.

CONCLUSION: Pre-ictal PSi was not associated with EEG-seizure duration.

EDITORIAL COMMENT: This study found no evidence to support a correlation between pre-ictal Patient State index and seizure duration, thereby challenging any clinical utility for guiding ECT administration.

OBJECTIVE: To estimate the cumulative incidence of diagnostic conversion from psychotic unipolar depression to bipolar and psychotic disorders in Sweden.

METHODS: Data from Swedish national registers were used to identify incident cases of psychotic unipolar depression between 2005 and 2011. To minimize the risk of misclassification, patients with a prior history of psychotic disorders, bipolar disorders, or manic episodes were excluded. Patients were followed until the first occurrence of a diagnostic change, death, or December 31, 2021. The cumulative incidence of diagnostic change was estimated using a competing risk model.

RESULTS: A total of 7836 patients diagnosed with psychotic depression between 2005 and 2011 were included. The median age at index diagnosis of psychotic depression was 49 years (interquartile range: 35-65), and 56.7% were women. By the end of follow-up, 28.8% (95% CI: 27.7-29.9) of patients had undergone a diagnostic change to either a psychotic or bipolar disorder. The cumulative incidence of conversion was higher to psychotic disorders (17.5%, 95% CI: 16.6-18.4) than to bipolar disorders (14.7%, 95% CI: 13.8-15.5). In a sensitivity analysis requiring at least two recorded diagnoses separated by ≥ 1 year, the overall incidence of diagnostic change decreased to 19.0% (95% CI: 18.1-20.0), with corresponding rates of 10.0% (95% CI: 9.3-10.7) to psychotic disorders and 9.8% (95% CI: 9.1-10.5) to bipolar disorders. Diagnostic conversion was more common among younger individuals.

CONCLUSION: Approximately 20%-30% of patients diagnosed with psychotic depression in secondary care in Sweden are expected to receive a subsequent diagnosis of a bipolar or psychotic disorder within 17 years. This has important clinical implications, as prognosis and treatment strategies differ between these conditions. Further research is needed to identify risk factors for diagnostic conversion to improve early detection and management.

BACKGROUND: While electroconvulsive therapy (ECT) is an effective treatment for depression, patient responses vary. In addition, there is a lack of guidance in making treatment decisions for patients with an initial nonresponsive trajectory. In this study, we aimed to identify distinct latent patient trajectories and explore outcomes among patients who had not responded after 9 treatments but who continued therapy.

METHODS: In this register-based cohort study, including 344 patients (61% female), we applied a latent class mixed model to identify latent patient trajectories and investigated variables associated with class affiliation in a multinomial regression analysis. We also identified nonresponders at treatment 9 and investigated final outcomes in a logistic regression model.

RESULTS: Three latent classes were identified, all of which showed improvement, although classes 2 and 3 showed faster and steeper symptom reduction, with mean Montgomery-Åsberg Depression Rating Scale (MADRS) scores post-ECT of 9.8 and 5.3, respectively. Class 1 showed a shallower response pattern, with a mean MADRS score post-ECT of 20.9; variables associated with affiliation to this class were longer duration of depressive episode, nonpsychotic depression, lower age, and lower baseline depression level. Of nonresponders to ECT at session 9, 44.9% achieved final response and 17.9% achieved remission; female sex and lower age groups (<60) were associated with higher odds of final nonresponse.

CONCLUSIONS: Our study supports ECT as an effective treatment for depression, while highlighting the existence of distinct response trajectories. A significant proportion of patients with an initial nonresponse trajectory may still benefit from continued ECT. Our findings reinforce the importance of individualized treatment decisions guided by clinical response and close monitoring.

INTRODUCTION: There is evidence that electroconvulsive therapy (ECT) can augment the effects of antipsychotics in schizophrenia. However, there is limited evidence from Western populations on whether ECT reduces the risk of relapse compared to non-ECT treatment in schizophrenia. This study aimed to compare time to psychiatric readmission or suicide among inpatients with schizophrenia treated with or without ECT, as well as those receiving index series with or without continuation ECT (C-ECT).

METHODS: Register-based study utilizing data from Swedish nationwide registers. Patients with schizophrenia who received both inpatient ECT and non-ECT treatment between 2011 and 2020 were included. Each patient served as their own control, contributing one admission with and without ECT. Admissions with or without ECT, as well as index series with or without C-ECT, were compared in univariate Cox regression analyses regarding time to psychiatric readmission or suicide within 30 days, 90 days, 180 days, and 1 year from discharge.

RESULTS: A total of 351 patients were included. Of these patients, 64.1% were male and the mean (SD) age was 48.2 (14.4) years. ECT was associated with longer time to readmission or suicide compared to non-ECT treatment within 30 days (HR: 0.66; 95% CI: 0.50-0.87; p = 0.003), 90 days (HR: 0.70; 95% CI: 0.56-0.87; p = 0.001), 180 days (HR: 0.68; 95% CI: 0.56-0.82; p = < 0.001), and 1 year from discharge (HR: 0.77; 95% CI: 0.65-0.91; p = 0.003). Furthermore, 15 patients received C-ECT, which was associated with longer time to readmission or suicide compared to index series without C-ECT within 90 days (HR: 0.13; 95% CI: 0.02-0.91; p = 0.040) and 180 days from discharge (HR: 0.26; 95% CI: 0.08-0.81; p = 0.021).

CONCLUSION: This study suggests that ECT can be associated with a longer time to relapse compared to non-ECT treatment in schizophrenia.

BACKGROUND: Electroconvulsive therapy (ECT) is the most effective treatment for severe and treatment-resistant depression, but its biological mechanisms remain poorly understood. Given the pivotal role of mitochondria in cellular energy metabolism and their proposed involvement in the pathology of depression, we aimed to investigate whether ECT alters mitochondrial metabolism.

METHODS: We included 102 patients with major depressive disorder referred for ECT at 7 Swedish hospitals. Fasting serum samples were collected at 3 time points: immediately before the first ECT session (T0), 30 minutes after the first session (T1), and before the sixth session (T2). Proton nuclear magnetic resonance spectroscopy was used to quantify metabolites related to the tricarboxylic acid cycle and amino acid metabolism.

RESULTS: Acutely (T0→T1), serum levels of citrate, glucose, glutamine, and pyruvate increased significantly, while formate and phenylalanine decreased. Across the treatment course (T0→T2), alanine and pyruvate levels increased, whereas the ketone bodies acetoacetate, acetone, and 3-hydroxybutyrate decreased significantly. An exploratory analysis indicated that the reduction in ketone bodies (T0→T2) was confined to patients showing clinical improvement, as defined by the Clinical Global Impressions-Improvement scale.

CONCLUSIONS: ECT induces both acute and sustained alterations in mitochondrial energy metabolism. These findings suggest that ECT modulates systemic mitochondrial function, warranting further investigation into how these metabolic changes relate to clinical improvement.

PURPOSE: Repetitive transcranial magnetic stimulation (rTMS) is an evidence‑based intervention for major depressive disorder (MDD) and treatment‑resistant depression (TRD). This study compared the regulatory, organizational, and clinical implementation of rTMS in Sweden and Japan between 2020 and 2024 and assessed alignment with international consensus recommendations.

MATERIALS AND METHODS: A cross‑sectional survey was conducted using publicly available information from rTMS‑providing facilities in both countries. Facilities confirming rTMS provision were included. Two investigators independently extracted facility‑level variables into a harmonized template covering service distribution, registry participation, stimulation protocols, device types, practitioner roles, eligibility criteria, reimbursement arrangements, and reported patient counts. Analyses were descriptive; financial variables were summarized to characterize access and were not part of a formal economic evaluation.

RESULTS: Both countries primarily used rTMS for MDD/TRD, required psychiatric assessment, and applied similar safety exclusions. Sweden delivered rTMS within a tax‑funded regional system, with 29 centres in 2024 and near‑complete participation in a national registry integrated with electronic health records; intermittent theta‑burst stimulation (iTBS) predominated. Japan had a mixed public-private model with 112 facilities and partial registry participation (62/112). Public insurance in Japan covered only a 10‑Hz left dorsolateral prefrontal cortex protocol, whereas private clinics frequently offered iTBS. Workforce roles, device diversity, and patient co‑payments differed, with greater financial barriers reported in Japan.

CONCLUSIONS: Differences in health‑system structure and registry completeness likely explain observed variation. Findings may inform policymakers seeking to optimize neuromodulation services, strengthen monitoring systems, and reduce access inequities.

OBJECTIVE: Repetitive transcranial magnetic stimulation (rTMS) has been demonstrated to be an effective and well tolerated treatment for depression, and it is being investigated also for other indications. This study presents the Swedish National Quality Register for rTMS (Q-rTMS). The registry comprises epidemiological data, data from standardized rating scales, details on treatment settings, and a registry-specific patient questionnaire.

METHODS: A presentation of the Q-rTMS including the types of data collected, the organizational structure of the register, as well as a brief overview of the volume of data accumulated between the registry's inception in 2018 and the end of 2024.

RESULTS: As of 2024, the register contained data from a total of 3083 unique individuals and 3842 treatment series, collected from 27 different rTMS providers. The most common indication for rTMS was depression (International Classification of Diseases, Tenth Revision diagnoses (ICD-10): F32-F34, 74.1%) followed by bipolar affective disorder (ICD-10: F31, 14.2%). The average age was 43.2 years, and 56.5% were women. The register included matched pre- and post-treatment data exceeding 60% completeness for the Montgomery-Åsberg Depression Rating Scale-Self Assessment (MADRS-S), the Clinical Global Impression-Severity (CGI-S), and the EuroQol five-dimensional questionnaire (EQ-5D-5L).

CONCLUSION: The Q-rTMS combines high coverage with longitudinal documentation of clinically relevant outcome measures and may hence contribute to population-based real-world effectiveness research in rTMS for depression.