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ECT and Depression
FEAST on a new approach to ECT
Steven Dubovsky, MD Reviewing Sahlem GL et al., J ECT 2016 Sep 32:197
Focal electrically administered seizure therapy (FEAST) is a relatively new approach to electroconvulsive therapy (ECT) designed to reduce adverse cognitive effects. It differs from ultrabrief pulse right unilateral (RUL) ECT in using unidirectional rather than bidirectional current and a novel nonsymmetric electrode placement (a large posterior electrode in front of the right motor cortex and a small anterior electrode above the center of the right eyebrow, over the right orbitofrontal cortex).
To record the efficacy, safety, and cognitive effects of FEAST, investigators conducted an open-label study in 20 adults with a severe major depressive episode (3 with bipolar illness; mean age, 49; mean 24-item Hamilton Rating Scale for Depression [HRSD] score, 37). After six treatments, those with inadequate response could increase dosage from six times to nine times the seizure threshold or switch to RUL. After an average of nine treatments, 13 patients met criteria for response (≥50% improvement in HRSD score), and 11 met criteria for remission (HRSD score, ≤10); quality-of-life scores improved significantly. In the five nonresponders who switched to RUL, depression responded in one and remitted in none. There was no evidence of cognitive deterioration (including anterograde or retrograde amnesia) with FEAST.
Comment
Some evidence shows that the antidepressant effect of ECT is related to suppression of prefrontal systems, whereas amnestic effects may be related to effects on medial temporal structures. Furthermore, the site of stimulation and the direction of current flow may be more important than seizure propagation for both effects. This study and a previous study of 17 depressed patients (Brain Stimul 2013; 6:403) provide a rationale for a double-blind comparison of RUL, FEAST, and sham ECT that could set a new standard for ECT practice.
Editor Disclosures at Time of Publication
Disclosures for Steven Dubovsky, MD at time of publication
Grant / Research support
Otsuka; Tower Foundation; Oshei Foundation; Patrick Lee Foundation; Wendt Foundation; Takeda; Lilly; Sumitomo; Hoffmann-La Roche; Pfizer, Neurim Pharmaceuticals; Neurocrine Biosciences
Editorial boards
Mind and Brain; Bulletin of the Menninger Clinic; Current Psychiatry; Journal of Psychosomatic Research
Citation(s):
Various mental health issues.
Two systems for fear and anxiety circuits. Advances in neuroscience have helped delineate fear- and anxiety-related circuits in the brain associated with many clinical anxiety disorders. Referring to “fear” as feelings that arise when a known threat of harm is immediate or imminent and to “anxiety” as feelings evoked by uncertain sources likely to cause harm in distal time or space, these authors critique earlier and simpler models of fear centers and related circuits.1 They propose that distinguishing two distinct but overlapping circuits, with subcortical and cortical anatomic correlates, may help further both clinical understanding and, ultimately, treatment — a “defensive survival circuit” responding to sensory input with defensive physiological reactions and behavioral actions, and a “cognitive circuit” that supports conscious feeling states and appraisal of threats. The authors contend that unpacking these two systems will lead to better individualized treatment (e.g., targeting one or the other system depending on individual symptom profiles) and more discriminating research.
Postpartum psychosis. Covering the epidemiology of postpartum psychosis and its diagnostic and clinical features, etiology, treatment, prevention, and needs for further treatment, this review offers clear-cut guidelines for diagnostic workup and specific treatment recommendations.2 The authors underscore considerations for safety planning for patients and infants, including urgent needs for inpatient care and the significant benefits of lithium and electroconvulsive therapy. Because relapse occurs in 31% of patients with isolated postpartum psychosis and because many patients manifest episodes after the postpartum period, usually of a bipolar-spectrum nature, diligent attention and ongoing monitoring are necessary.
Mental and substance use disorders: Treatment challenges. The authors of this health policy report3 comprehensively examine the major issues regarding mental and substance use disorders in U.S. healthcare today: They are highly prevalent and disabling, but infrequently and ineffectively treated. Barriers include continuing insurance limitations despite parity laws; a shrinking supply of psychiatrists, many of whom do not accept insurance; and poor access to care for disadvantaged populations who suffer disproportionately from these disorders. Separation of medical and mental health systems are being addressed with models of integrated care, which are being encouraged by the Affordable Care Act and by medical societies and some insurance companies. However, insurance limitations and continuing differences in the culture of medical and mental health systems and providers impose challenges. Actual legislation may be required to effect change but may be difficult in the current political environment. This essay is must reading for any psychiatrist interested in understanding the care-delivery landscape and its possible future.
Bipolar disorder in primary care practices. Although most primary care physicians are well acquainted with managing uncomplicated depression, they also encounter numerous other psychiatric disorders. These authors have conducted a meta-analysis of 16 studies (425,691 participants) to determine the prevalence of bipolar disorders in primary care practice.4 They estimate the prevalence of bipolar disorder in primary care to be 1.9% globally (pooled prevalence across 8 studies reporting only current diagnosis, 3.7%) and 3.7% in North America. (Based on other data from 226 practices across 43 U.S. states comparing the prevalence rates of 24 diseases [J Am Board Fam Med 2013; 26:518], this study's findings would result in ranking bipolar disorders as 14th in a list of common chronic conditions, just after chronic obstructive pulmonary disease [prevalence, 4.35%] and just before chronic kidney disease [prevalence, 3.37%]. Depression was rated third [prevalence, 18.67%].)
These findings suggest both that primary care physicians should become well acquainted with the management of bipolar disorders and that psychiatrists working in integrated-care settings can expect bipolar disorder to be a common reason for referral.
Migraines and psychiatric disorders: A complex relationship. The co-occurrence of migraine headaches and psychiatric disorders is common. Here, the authors comprehensively review the association, the etiologic connections, and treatment implications.5 They note a bidirectional effect: Migraine is more common in patients who have depression, anxiety, and bipolar disorder, and depression, anxiety, and bipolar disorder are more common in those who have migraines. Stress can be a trigger for migraine, but stress reduction is also associated with increased migraine risk. Post-traumatic stress disorder, but not trauma, increases migraine risk — an interesting observation that should be studied in individuals with mild traumatic brain injury and comorbid migraines. Psychiatric disorders are associated with migraine “chronification”; thus, recognition and treatment are important. This article is important for all clinicians.
Borderline personality disorder in the elderly. What happens with older patients with borderline personality disorder? These authors have reviewed studies involving patients over age 65 and longitudinal studies of patients over age 50.6 The reviewers suggest that as patients age, impulsive and identity disturbance diminish, but depression, emptiness, and somatic complaints worsen. Suicide attempts are less frequent but may become more lethal. Emotional dysregulation, intense anger, unstable relationships, and attachment insecurity persist, often affecting patients' health behaviors.
Basics of poststroke depression. Reviewing diagnosis, neurobiological mechanisms, prognosis, and treatment of poststroke depression, these authors report that clinically significant depression occurs in about 30% to 50% of patients after cerebrovascular accidents.7 Depression is strongly linked to stroke severity and is further associated with poststroke mortality, largely due to cardiovascular causes. Giving antidepressant medication to depressed poststroke patients, whether or not the patient was depressed prior to stroke, is associated with improved survival. This practice, recommended by the American Heart Association, should be continued for >6 months after recovery.
ECT and Depression
FEAST on a new approach to ECT
Steven Dubovsky, MD Reviewing Sahlem GL et al., J ECT 2016 Sep 32:197
Focal electrically administered seizure therapy (FEAST) is a relatively new approach to electroconvulsive therapy (ECT) designed to reduce adverse cognitive effects. It differs from ultrabrief pulse right unilateral (RUL) ECT in using unidirectional rather than bidirectional current and a novel nonsymmetric electrode placement (a large posterior electrode in front of the right motor cortex and a small anterior electrode above the center of the right eyebrow, over the right orbitofrontal cortex).
To record the efficacy, safety, and cognitive effects of FEAST, investigators conducted an open-label study in 20 adults with a severe major depressive episode (3 with bipolar illness; mean age, 49; mean 24-item Hamilton Rating Scale for Depression [HRSD] score, 37). After six treatments, those with inadequate response could increase dosage from six times to nine times the seizure threshold or switch to RUL. After an average of nine treatments, 13 patients met criteria for response (≥50% improvement in HRSD score), and 11 met criteria for remission (HRSD score, ≤10); quality-of-life scores improved significantly. In the five nonresponders who switched to RUL, depression responded in one and remitted in none. There was no evidence of cognitive deterioration (including anterograde or retrograde amnesia) with FEAST.
Comment
Some evidence shows that the antidepressant effect of ECT is related to suppression of prefrontal systems, whereas amnestic effects may be related to effects on medial temporal structures. Furthermore, the site of stimulation and the direction of current flow may be more important than seizure propagation for both effects. This study and a previous study of 17 depressed patients (Brain Stimul 2013; 6:403) provide a rationale for a double-blind comparison of RUL, FEAST, and sham ECT that could set a new standard for ECT practice.
Editor Disclosures at Time of Publication
Disclosures for Steven Dubovsky, MD at time of publication
Grant / Research support
Otsuka; Tower Foundation; Oshei Foundation; Patrick Lee Foundation; Wendt Foundation; Takeda; Lilly; Sumitomo; Hoffmann-La Roche; Pfizer, Neurim Pharmaceuticals; Neurocrine Biosciences
Editorial boards
Mind and Brain; Bulletin of the Menninger Clinic; Current Psychiatry; Journal of Psychosomatic Research
Citation(s):
- Sahlem GL et al. Expanded safety and efficacy data for a new method of performing electroconvulsive therapy: Focal electrically administered seizure therapy. J ECT 2016 Sep; 32:197. (http://dx.doi.org/10.1097/YCT.0000000000000328)
Various mental health issues.
Two systems for fear and anxiety circuits. Advances in neuroscience have helped delineate fear- and anxiety-related circuits in the brain associated with many clinical anxiety disorders. Referring to “fear” as feelings that arise when a known threat of harm is immediate or imminent and to “anxiety” as feelings evoked by uncertain sources likely to cause harm in distal time or space, these authors critique earlier and simpler models of fear centers and related circuits.1 They propose that distinguishing two distinct but overlapping circuits, with subcortical and cortical anatomic correlates, may help further both clinical understanding and, ultimately, treatment — a “defensive survival circuit” responding to sensory input with defensive physiological reactions and behavioral actions, and a “cognitive circuit” that supports conscious feeling states and appraisal of threats. The authors contend that unpacking these two systems will lead to better individualized treatment (e.g., targeting one or the other system depending on individual symptom profiles) and more discriminating research.
Postpartum psychosis. Covering the epidemiology of postpartum psychosis and its diagnostic and clinical features, etiology, treatment, prevention, and needs for further treatment, this review offers clear-cut guidelines for diagnostic workup and specific treatment recommendations.2 The authors underscore considerations for safety planning for patients and infants, including urgent needs for inpatient care and the significant benefits of lithium and electroconvulsive therapy. Because relapse occurs in 31% of patients with isolated postpartum psychosis and because many patients manifest episodes after the postpartum period, usually of a bipolar-spectrum nature, diligent attention and ongoing monitoring are necessary.
Mental and substance use disorders: Treatment challenges. The authors of this health policy report3 comprehensively examine the major issues regarding mental and substance use disorders in U.S. healthcare today: They are highly prevalent and disabling, but infrequently and ineffectively treated. Barriers include continuing insurance limitations despite parity laws; a shrinking supply of psychiatrists, many of whom do not accept insurance; and poor access to care for disadvantaged populations who suffer disproportionately from these disorders. Separation of medical and mental health systems are being addressed with models of integrated care, which are being encouraged by the Affordable Care Act and by medical societies and some insurance companies. However, insurance limitations and continuing differences in the culture of medical and mental health systems and providers impose challenges. Actual legislation may be required to effect change but may be difficult in the current political environment. This essay is must reading for any psychiatrist interested in understanding the care-delivery landscape and its possible future.
Bipolar disorder in primary care practices. Although most primary care physicians are well acquainted with managing uncomplicated depression, they also encounter numerous other psychiatric disorders. These authors have conducted a meta-analysis of 16 studies (425,691 participants) to determine the prevalence of bipolar disorders in primary care practice.4 They estimate the prevalence of bipolar disorder in primary care to be 1.9% globally (pooled prevalence across 8 studies reporting only current diagnosis, 3.7%) and 3.7% in North America. (Based on other data from 226 practices across 43 U.S. states comparing the prevalence rates of 24 diseases [J Am Board Fam Med 2013; 26:518], this study's findings would result in ranking bipolar disorders as 14th in a list of common chronic conditions, just after chronic obstructive pulmonary disease [prevalence, 4.35%] and just before chronic kidney disease [prevalence, 3.37%]. Depression was rated third [prevalence, 18.67%].)
These findings suggest both that primary care physicians should become well acquainted with the management of bipolar disorders and that psychiatrists working in integrated-care settings can expect bipolar disorder to be a common reason for referral.
Migraines and psychiatric disorders: A complex relationship. The co-occurrence of migraine headaches and psychiatric disorders is common. Here, the authors comprehensively review the association, the etiologic connections, and treatment implications.5 They note a bidirectional effect: Migraine is more common in patients who have depression, anxiety, and bipolar disorder, and depression, anxiety, and bipolar disorder are more common in those who have migraines. Stress can be a trigger for migraine, but stress reduction is also associated with increased migraine risk. Post-traumatic stress disorder, but not trauma, increases migraine risk — an interesting observation that should be studied in individuals with mild traumatic brain injury and comorbid migraines. Psychiatric disorders are associated with migraine “chronification”; thus, recognition and treatment are important. This article is important for all clinicians.
Borderline personality disorder in the elderly. What happens with older patients with borderline personality disorder? These authors have reviewed studies involving patients over age 65 and longitudinal studies of patients over age 50.6 The reviewers suggest that as patients age, impulsive and identity disturbance diminish, but depression, emptiness, and somatic complaints worsen. Suicide attempts are less frequent but may become more lethal. Emotional dysregulation, intense anger, unstable relationships, and attachment insecurity persist, often affecting patients' health behaviors.
Basics of poststroke depression. Reviewing diagnosis, neurobiological mechanisms, prognosis, and treatment of poststroke depression, these authors report that clinically significant depression occurs in about 30% to 50% of patients after cerebrovascular accidents.7 Depression is strongly linked to stroke severity and is further associated with poststroke mortality, largely due to cardiovascular causes. Giving antidepressant medication to depressed poststroke patients, whether or not the patient was depressed prior to stroke, is associated with improved survival. This practice, recommended by the American Heart Association, should be continued for >6 months after recovery.
- 1.
LeDoux JE and Pine DS.Using neuroscience to help understand fear and anxiety: A two-system framework. Am J Psychiatry 2016 Sep 9; [e-pub]. (http://dx.doi.org/10.1176/appi.ajp.2016.16030353)
- 2.
Bergink V et al. Postpartum psychosis: Madness, mania, and melancholia in motherhood. Am J Psychiatry 2016 Sep 9; [e-pub]. (http://dx.doi.org/10.1176/appi.ajp.2016.16040454)
- 3.
Huskamp HA and Iglehart JK.Mental health and substance-use reforms — milestones reached, challenges ahead. N Engl J Med 2016 Aug 18; 375:688. (http://dx.doi.org/10.1056/NEJMhpr1601861)
- 4.
Stubbs B et al. How common is bipolar disorder in general primary care attendees? A systematic review and meta-analysis investigating prevalence determined according to structured clinical assessments. Aust N Z J Psychiatry 2016 Jul; 50:631. (http://dx.doi.org/10.1177/0004867415623857)
Abstract/FREE Full Text
- 5.
Minen MT et al. Migraine and its psychiatric comorbidities. J Neurol Neurosurg Psychiatry 2016 Jul; 87:7415. (http://dx.doi.org/10.1136/jnnp-2015-312233)
- 6.
Beatson J et al. Missed diagnosis: The emerging crisis of borderline personality disorder in older people. Aust N Z J Psychiatry 2016 Apr 6; [e-pub]. (http://dx.doi.org/10.1177/0004867416640100)
- 7.
Robinson RG and Jorge RE.Post-stroke depression: A review. Am J Psychiatry 2016 Mar; 173:221. (http://dx.doi.org/10.1176/appi.ajp.2015.15030363)
Being told you're delusional does not necessarily mean you're mental.
