Hopelessness and suicidal ideation in outpatients with treatment-resistant depression: prevalence and impact on treatment outcome

Depression and hopelessness are risk factors for suicide. The purpose of this study was to examine the extent of suicidal ideation and hopelessness in outpatients with treatment-resistant depression (TRD) and to study the impact of suicidal ideation and hopelessness on treatment with nortriptyline (NT). The degree of suicidal ideation and hopelessness was assessed during the screen visit with the use of items #3 and #30 of the Hamilton Depression Rating Scale (HAM-D) in 89 patients with TRD who entered a 6-week open trial of NT. Forty of these patients also completed the Beck Hopelessness Index (BHI) during the screen visit. In separate logistic regressions, the scores from the BHI and the two HAM-D items were then tested as predictors of clinical response to the 6-week trial with NT, controlling for the severity of depression. More than half of patients reported thoughts or wishes of death to self and significant hopelessness. A greater degree of hopelessness before treatment in completers, reflected by the score on the HAM-D item #30, predicted response to NT. More than half of patients with prominent hopelessness who completed the trial responded. Patients with TRD are more likely than not to report prominent suicidal ideation and hopelessness. Furthermore, a full 6-week trial of NT, a relatively noradrenergic tricyclic antidepressant, may be particularly useful in patients who have failed to respond to several antidepressants and also report significant hopelessness.     

Psychosocial functioning in patients with treatment resistant depression.

BACKGROUND: Depression is a disorder that causes disability, with a profound adverse impact on all areas of psychosocial functioning. This is particularly true for those with treatment resistant depression (TRD). However, to date, no systematic assessments of psychosocial functioning for patients with TRD have been conducted. METHODS: In the present study, we used the Longitudinal Interval Follow-up Evaluation (LIFE) scale to measure psychosocial functioning in 92 patients with TRD. These patients met formal criteria for TRD and were part of a clinical trial examining the efficacy of lithium augmentation of nortriptyline. RESULTS: Clinicians rated this sample of patients as experiencing mild to moderate impairment in work-related activities, good to fair interpersonal relations, poor level of involvement in recreational activities, and mild impairment of ability to enjoy sexual activity. Patients and clinicians rated global social adjustment as poor. CONCLUSIONS: Patients with formally defined TRD experience significant impairment in psychosocial functioning. In this sample a tendency existed for both clinicians and patients to assign more severely impaired global ratings when compared with ratings for specific functional areas.     

Serum cholesterol in treatment-resistant depression

OBJECTIVE: Patients with major depressive disorder (MDD) may have significant differences in cholesterol levels compared with healthy controls. A previous study by our group reported that depressed patients with elevated cholesterol levels (>or=200 mg/dl) were significantly more likely to be nonresponders to fluoxetine treatment than depressed patients with nonelevated cholesterol levels. However, very little is known regarding cholesterol in patients with treatment-resistant depression (TRD). The purpose of this study was to compare cholesterol levels at baseline between depressed patients with and without TRD and to test whether cholesterol levels at baseline can predict clinical response in patients with TRD treated with open-label nortriptyline (NT). METHODS: Ninety-two patients with TRD entered a 6-week open trial of NT. Baseline cholesterol levels were randomly collected for 59 of these patients. Controlling for age and gender, we compared baseline cholesterol and triglyceride levels for 35 patients with TRD who did not respond to NT with 205 non-TRD patients who responded to an 8-week open trial of fluoxetine. Furthermore, with the use of logistic regression, we tested whether baseline cholesterol levels predicted clinical response to NT in the patients with TRD. RESULTS: Patients with TRD had higher triglyceride levels at baseline compared with depressed patients without TRD. Cholesterol defined as a dichotomous variable being elevated if equal to or greater than 200 mg/dl, predicted poor response to a 6-week open trial of NT in patients with TRD. CONCLUSIONS: The results of this study confirm the relationship between hypercholesterolemia and poor outcome in the treatment of MDD for patients with TRD.     

The impact of neurocognitive impairment on occupational recovery of clinically stable patients with bipolar disorder: a prospective study

Bearden CE, Shih VH, Green MF, Gitlin M, Sokolski KN, Levander E, Marusak S, Hammen C, Sugar CA, Altshuler LL. The impact of neurocognitive impairment on occupational recovery of clinically stable patients with bipolar disorder: a prospective study.
Bipolar Disord 2011: 13: 323–333. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objective: Many patients with bipolar disorder do not regain their premorbid level of occupational functioning even after mood episodes have resolved. The reasons for this are not well understood. We evaluated the relationship between neurocognition and occupational function in bipolar disorder patients, following symptomatic recovery. Methods: A total of 79 previously employed adults with bipolar I disorder who achieved symptomatic recovery (i.e., at least six weeks clinically euthymic) following a manic episode underwent a neurocognitive evaluation and assessment of occupational functioning. Study participants were evaluated every three months thereafter for up to nine months. Factor analysis was applied to reduce the initial set of neurocognitive variables to five domains: episodic memory, working memory/attention, executive function, visual scanning, and speed of processing. Multiple logistic regression models were used to examine the joint predictive values of these domains for determining occupational recovery. Results: At the time of symptomatic recovery, four of five neurocognitive factors were significant predictors of concomitant occupational recovery and the fifth, executive function, showed a trend in the same direction. For those not occupationally recovered at baseline, longitudinal analyses revealed that changes between baseline and the three‐month follow‐up timepoint in most cognitive domains were robust and highly significant predictors of occupational recovery at three months. Conclusions: These findings indicate that better neurocognitive function in multiple domains and improvement in these domains over time are strongly predictive of subsequent occupational recovery. Treatments that target cognitive deficit may therefore have potential for improving long‐term vocational functioning in bipolar illness.     

Understanding who improves after psychiatric hospitalization

This study attempts to identify variables associated with improved functioning after psychiatric hospitalization. The relationship between 25 clinical and demographic variables and improvements and functioning at discharge of 309 consecutive patients in an open ward over 2 years were studied using stepwise logistic regression. Measures of patient functioning at discharge were score above or below 50 on the (Global Assessment of Functioning scale) (GAF) and 3-point scale of functioning 1 week after discharge (needs constant supervision, functions independently at home, functions on the job). We created a logistic regression model of outcome based on the information available at admission and one based also on information at time of discharge (i.e., medication, therapy and length of stay etc.). Discharge models predicted 6–10% better than admission models. Discharge models correctly predicted whether GAF level was above 50 in 72% of the cases and return to preadmission functioning in 71% of the cases. We also created a model of functioning at discharge using a hierarchical logistic regression model. It correctly predicted 74% of the lowest level of functioning, 47% of the middle level and 68% of the highest level. The best predictors of improved functioning after discharge were preadmission levels of functioning, psychotherapy in hospital, absence of organic brain syndrome, attendance at occupational therapy and hospitalization less than 4 months. Diagnosis had almost no discernible effect on outcome of hospitalization.     

Predictors of outcome in treatment of opiate addicts: Evidence for the multidimensional nature of addicts' problems

This report describes the characteristics of treatment outcome and the relationship between predictors and outcome in a sample of opiate addicts who were first evaluated on admission to a drug dependence treatment unit and then reevaluated 6 months later. Results indicate the independence of five different aspects of treatment outcome in opiate addicts including program retention, psychological symptoms, illicit drug use, illegal activities and occupational functioning. Evaluation of the relationship between seven categories of predictor variables and the different outcome factors revealed that the stronger predictors of outcome were indices of past functioning in that area, with, for example, pretreatment occupational functioning being the best predictor of occupational functioning following entrance to treatment. In addition, no single category of predictors was significantly related to all of the outcome factors. These findings are interpreted as supporting a multidimensional approach to the understanding and assessment of addicts' functioning.     

Predictors of occupational status six months after hospitalization in persons with a recent onset of psychosis

Participation in work or school activity is an important aspect of social functioning in individuals with a recent onset of psychosis. We measured the predictors of occupational status 6 months following hospitalization in a sample of 71 adults with recent onset affective or non-affective psychosis. At baseline, participants were evaluated with cognitive measures including the Wisconsin Card Sorting Test, symptom rating scales, the Modified Vocational Index to assess occupational status, and other clinical and demographic measures. At follow-up, occupational status was re-assessed and categorized as whether or not the patient had any current work or school activity. Results of a backwards stepwise logistic regression examining occupational status at follow-up yielded a significant model with the following independent predictors: a higher baseline level of cognitive functioning as measured by performance on the Wisconsin Card Sorting Test lower level of baseline depression as measured by the Calgary Depression Scale; and better socioeconomic status as measured by level of maternal education. Cognitive functioning, but not psychosis severity, is a significant independent predictor of occupational status early in the course of psychotic illness.     

Somatic symptoms in treatment-resistant depression

The purpose of this work was to study the prevalence of somatic symptoms in patients with treatment-resistant depression (TRD) and their impact on the response to antidepressant treatment. Somatic symptoms were assessed during the screen visit with the Symptom Questionnaire (SQ) somatic symptom (SQ-SS) and somatic well-being sub-scales (SQ-SWB) in 40 patients with TRD enrolled in a 6-week open trial of nortriptyline. A logistic regression was used to test whether SQ-SS or SQ-SWB scores predicted clinical response to nortriptyline. Ninety-five percent of patients reported at least one somatic symptom. Higher SQ-SS scores during the screen visit predicted poorer response to nortriptyline. There was a trend for lower SQ-SWB scores to predict poor response to nortriptyline. None of the patients with SQ-SS scores above the mean for the sample responded to nortriptyline. The overwhelming majority of patients with TRD presented with somatic symptoms. In addition, a greater number of somatic symptoms during the screen visit placed patients at risk for further treatment resistance.     

Risk and protective factors predicting multiple suicide attempts

This study compared demographical and clinical variables between first and multiple suicide attempters and investigated risk and protective factors predicting multiple attempts. 228 patients visiting emergency department after attempting suicide were divided into two groups: first attempter (n=148, 64.9%) and multiple attempter (n=80, 35.1%). Demographic variables, clinical characteristics, factors related with suicide behavior, and psychiatric resources between two groups were compared. Multivariate logistic regression analysis was conducted to investigate risk and protective factors predicting multiple attempts. The results showed that multiple attempters were younger, not married, more severe in psychopathology (e.g., psychiatric disorder, personality disorder, lower function, and suicide family history) and suicidality (e.g., repetitive/severe/continuous suicide ideation), and lower in psychiatric resources (e.g., interpersonal stress/conflict, conflicting interpersonal relationship, socially isolated, lower personal achievement, and lower ability to control emotion) than first attempters. Suicide ideation severity and conflicting interpersonal relationships predicted multiple suicide attempts, whereas past year's highest global functioning score and age over 45 protected against multiple suicide attempts. This study demonstrated that multiple suicide attempters have more severe clinical profile than first suicide attempters. Moreover, decreasing severity of suicide ideation, improving interpersonal relationships, and enhancing functioning level of suicide attempters might be important in preventing them from re-attempting suicide.     

Axis III disorders in treatment-resistant major depressive disorder

A number of naturalistic studies have found that medical co-morbidity conveys a worse long-term prognosis in the treatment of major depressive disorder (MDD). The purpose of this study was to test whether the presence of co-morbid medical conditions can predict clinical response in patients with treatment-resistant MDD (TRD) treated with open-label nortriptyline (NT). Ninety-two patients with TRD entered a 6-week open trial of NT. The presence of co-morbid medical disorders was assessed during the screen visit. The degree of medical co-morbidity during the screen visit was then quantified with the use of the Cumulative Illness Rating Scale-Geriatric Version (CIRS(G)). We tested whether CIRS(G) scores predicted clinical response or depression severity at endpoint. CIRS scores at baseline did not significantly predict treatment response. The results of this study fail to confirm the relationship between co-morbid medical conditions and poor outcome in the treatment of MDD for patients with TRD. Patients with TRD and co-morbid medical conditions can be expected to respond to antidepressants as well as their counterparts without concurrent axis III co-morbidity. The CIRS(G) scores for this TRD sample were lower than those reported for geriatric depression, or for depressed patients with severe medical illness, common in medical and surgical wards and in most specialty clinics of large academic centers. Thus, the present results cannot be generalized to such populations.     

Promoting recovery of sexual functioning after radical prostatectomy with group-based stress management: the role of interpersonal sensitivity

OBJECTIVE: Treatment for localized prostate carcinoma (PCa) is frequently associated with decrements in sexual functioning and satisfaction. Given the highly interpersonal nature of these decrements, interpersonal problems (such as interpersonal sensitivity) may affect recovery of sexual functioning after PCa treatment through interference with physician and partner communication and through distorted cognitions surrounding sexual dysfunction. The objective of the present study was to determine the effect of interpersonal sensitivity on several treatment indicators, including response to a group-based psychosocial intervention. METHODS: Participants were 101 older men recovering from radical prostatectomy who were enrolled in a randomized controlled trial of a 10-week group-based cognitive-behavioral stress management (CBSM) intervention. Measures included the Inventory of Interpersonal Problems and the sexual functioning subscale of the University of California-Los Angeles quality-of-life measure. RESULTS: At baseline, interpersonal sensitivity was related to a belief linking sexual dysfunction to core male identity (r=.29, P<.05). Using hierarchical regression, we found that (a) the CBSM intervention was effective in promoting sexual recovery in all participants, and (b) this effect was moderated by interpersonal sensitivity, such that individuals with higher levels of interpersonal sensitivity made larger improvements in sexual functioning in response to CBSM. CONCLUSIONS: CBSM was effective in improving sexual function after radical prostatectomy. Individuals with higher levels of interpersonal sensitivity were more likely to perceive sexual dysfunction as a threat to masculine identity and made larger gains in the CBSM intervention. Results and relevance to the older male cancer patients are discussed from the perspective of interpersonal theory.     

Unemployment and emergency room visits predict poor treatment outcome in primary care panic disorder

BACKGROUND: To complement existing data on predictors of treatment response in groups of "pure" panic disorder patients studied in clinical trials or in poorly controlled naturalistic follow-up, we sought to elucidate predictors of treatment response over 1 year in a diagnostically heterogeneous and comorbidly ill group of primary care patients with panic disorder participating in a randomized effectiveness study. METHOD: Patients with DSM-IV panic disorder (N = 115), mostly without agoraphobia, were recruited from 3 primary care clinics in Seattle, Wash., and randomly assigned to an on-site collaborative care intervention (N = 57), in which psychiatrists provided education, 2 visits, follow-up phone calls, and paroxetine, or to usual care by their primary care physician (N = 58). Predictors of response at 3-month intervals over 1 year were determined using logistic regression analysis. RESULTS: Patients with consistent response over the year (response at the majority of available timepoints) were significantly (p <.05) more likely to be white, employed, in higher income strata, and in the intervention group and had less medical comorbidity and phobia severity, fewer recent hospitalizations and emergency room visits, and higher reported Medical Outcomes Study 36-Item Short Form physical and role functioning. The final regression model indicated that responders were more likely to be in the intervention group, be employed, and lack a recent emergency room visit. CONCLUSION: While some of the univariate findings partially replicate previous results linking greater illness severity with poorer response, univariate findings linking medical comorbidity and low socioeconomic status with poor response, as well as multivariate findings that unemployment and recent emergency room use are the most potent predictors of poor response, have not been previously reported.     

The development of subjective quality of life over the first 2 years in first-episode psychosis

The main aim of this study was to examine changes in subjective quality of life (general s-QoL) in patients with first-episode psychosis from baseline to 2 years follow-up. A total of 201 of 252 patients had full quality of life assessment at both baseline and at 2 years. Repeated measure analyses of variance were done to evaluate the development over time, and multiple linear regression analyses to evaluate predictors of change. These patients with a first-episode psychosis showed a significant improvement in general s-QoL during the first 2 years of treatment. Improvements in general s-QoL were associated with increase in excitative symptoms and with improvements in depressive symptoms, global functioning, level of daily activities, level of social activities, and perceived general health.     

Clinical issues in considering vagus nerve stimulation for treatment-resistant depression

This review briefly discusses the clinical and basic science rationale for vagus nerve stimulation (VNS) in treatment-resistant depression (TRD). As the number of treatment failures for depression increases, the likelihood of achieving remission during acute treatment decreases, and the risk of relapse increases with the number of treatment failures. Two open trials of adjunctive VNS for TRD showed positive acute results and a growing benefit over time. The results of the acute randomized controlled trial were not significant for the primary outcome (response by HRSD-24), but the secondary measure (IDS-SR-30) was significant for VNS. A 12-month nonrandomized comparative analysis of patients receiving adjunctive VNS with TRD patients receiving treatment as usual showed significant results favoring VNS. Post hoc analyses found that this difference was not accounted for baseline differences nor by intercurrent treatment. While VNS is well tolerated, the optimal dosing strategies have not been determined nor have clinically useful predictors of who will respond to the treatment. Given the profound effects of TRD upon the daily lives of patients and that a substantial number of VNS patients receive benefit, VNS is a useful option for managing patients with TRD.     

Association between cognitive function, behavioral syndromes and two-year clinical outcome in Chinese subjects with late-onset Alzheimer's disease

OBJECTIVE: To examine associations between behavioral and psychological symptoms of dementia (BPSD), cognitive function and clinical deterioration over 2 years. METHODS: One hundred and four Chinese subjects with late-onset Alzheimer's Disease (AD) who presented to psychogeriatric clinics were followed for an average of 22.5 months. BPSD subgroups were categorized by latent class analysis using the Neuropsychiatric Inventory. Comprehensive cognitive profiles were performed with the Mattis Dementia Scale, the Hong Kong List Learning Test (HKLLT) and the Category Verbal Fluency Test. Interactions between cognitive function and behavioral syndromes were evaluated. Potential predictors for clinical deterioration were computed with logistic regression analysis. RESULTS: Three latent classes of subjects with similar behavioral syndromes were identified: Low BPSD (44%), Affective (32%) and Psychosis (24%) groups. Association between cognitive functions and BPSD was not significant. At follow-up, a higher proportion of subjects in the Affective (70%) and Low BPSD (49%) groups remained stable at the same Clinical Dementia Rating. Baseline scores in the "recognition" test of the HKLLT and age were significant predictors for "deceased" status at 2-year follow-up. CONCLUSION: The lack of association between behavioral syndromes and cognitive function suggests that these relatively independent dimensions of dementia should be examined individually for different prognostic significance.     

Correlates of suicidal ideation in general healthcare patients - Results of the WHO Collaborative Study on Psychological Problems in General Health Care (WHO-PPGHC)

In the WHO study on Psychological Problems in General Health Care (WHO-PPGHC), a random sample of 5438 patients from 15 international centres were investigated to study prevalence and type of mental disorders by use of standardized methods. Using the General Health Questionnaire, 9.7% of the practice attenders admitted that they have or recently had suicidal ideations. In a logistic regression analysis, predictors of suicidal ideation were hopelessness, presence of an ICD-10 diagnosis, social disability in terms of occupational role functioning and daily routine, and lack of social adaptation in terms of lower age and being less educated. The predictors are discussed in an explanatory model of suicidal ideation in general healthcare. Implications for patient care in general healthcare are discussed.     

History of depression and women's current health and functioning during midlife

OBJECTIVE: To examine the association of past depression with current physical and mood symptoms and functioning in a community cohort of middle-aged African-American, White, and Hispanic women without current depression and whether the associations varied by severity of prior depression. METHODS: The study was conducted as part of a longitudinal multisite investigation of middle-aged women's health, the Study of Women's Health Across the Nation (SWAN). Nine hundred twenty-two women, aged 42-52 years, participated in The Structured Clinical Interview for the Diagnosis of DSM-IV Axis I Disorders (SCID) at study entry at three SWAN sites; 780 did not have current depression and formed the analytic sample. chi(2), ANOVAs and Cochran-Armitage Trend tests were conducted as appropriate to evaluate bivariate relationships between history of major depression and covariates and outcomes. Multivariable logistic regression analyses included significant covariates in final analyses. RESULTS: Women (24.3%) had a history of major depression: 14.9% single episode, 9.4% recurrent and 12.6% had minor depression. In multivariable logistic regression analyses, compared to no history of depression, any past depression predicted high body pain [odds ratios (ORs), 1.8-2.3; 95% CIs, 1.05-4.02]. Recurrent depression predicted poor social functioning (OR, 2.1; 95% CI, 1.20-3.80) and current treatment for back pain (OR, 4.2; 95% CI, 1.78-9.82). Minor depression predicted mood symptoms (OR, 1.9; 95% CI, 1.16-3.20). CONCLUSIONS: Midlife women with past major or minor depression are at risk for physical symptoms, body pain, and poor social functioning even in the absence of current depression. Primary care providers may underestimate the health impact of prior depression without current depression.     

Dimensional measures of personality as a predictor of outcome at 5-year follow-up in women with bulimia nervosa

Dimensional models are commonly used as a supplement to the categorical model within the field of personality disorders. The purpose of this study was to examine personality dimensions as predictors of 5-year outcomes among women with bulimia nervosa. One hundred and thirty-four women with bulimia nervosa participated in a randomised psychotherapy treatment trial. Data was available for 109 out of the 134 participants at follow-up. Outcomes were the presence of any eating disorder (past year), the presence of a mood disorder episode (past year), and the global assessment of functioning at 5-year follow-up. Self-directedness was the only predictor of any eating disorder diagnosis (past year) at 5-year follow-up. Asceticism significantly predicted the presence of a mood disorder episode (past year) at 5 years. Borderline personality disorder symptoms predicted global functioning at 5 years. These results suggest that high self-directedness at pre-treatment may offer potential prognostic information regarding eating disorder status 5 years post-treatment. Furthermore, no single measure predicted outcome for all variables (any eating disorder diagnosis, a mood disorder episode (past year), or global functioning) at 5-year follow-up. This suggests that a comprehensive personality assessment using multiple measures is desirable for predicting outcomes.     

Evaluation of combination therapy using aciclovir and corticosteroid in adult patients with herpes simplex virus encephalitis

OBJECTIVE: Herpes simplex virus encephalitis (HSVE) is associated with significant morbidity and mortality, even with appropriate antiviral therapy. In the present investigation, the first to assess efficacy of corticosteroid treatment with aciclovir therapy in HSVE, multiple logistic regression analysis was performed of predictors of outcome in adult patients with HSVE. METHODS: A non-randomised retrospective study of 45 patients with HSVE treated with aciclovir was conducted. The patients were divided into poor and good groups based on outcome at three months after completion of aciclovir treatment. The variables evaluated were: clinical variables (sex, age, days after onset at initiation of aciclovir, Glasgow Coma Scale (GCS) at initiation of aciclovir, initial and maximum values for the cell numbers and protein concentration in the cerebrospinal fluid, and corticosteroid administration); neuroradiological variables (detection of lesions by initial cranial computed tomography and by initial magnetic resonance imaging); and one neurophysiological variable (detection of periodic lateralised epileptiform discharges on the initial electroencephalogram). Single variable logistic regression analysis was performed followed by multiple logistic regression analysis. The best set of predictors for the outcome of HSVE was estimated by stepwise logistic regression analysis. RESULTS: A poor outcome was evident with older age, lower GCS score at initiation of aciclovir, and no administration of corticosteroid. Patient age, GCS at initiation of aciclovir, and corticosteroid administration were found to be significant independent predictors of outcome on multiple logistic regression analysis, and these three variables also formed the best set of predictors (R(2) = 0.594, p<0.0001). CONCLUSION: Combination therapy using both aciclovir and corticosteroid represents one of the predictors of outcome in HSVE.     

Ett fall av generaliserad,retrograd amnesi

Abstract

Nordenskjöld A, von Knorring L, Brus O, Engström I. Predictors of regained occupational functioning after electroconvulsive therapy (ECT) in patients with major depressive disorder—A population based cohort study. Nord J Psychiatry 2012;Early Online:1–8. 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.