Metabolic changes in the brain of patients with late-onset major depression

Positron emission tomography (PET) with fluorodeoxyglucose-F18 was used to examine glucose metabolism in patients with late-onset major depression, all hospitalized non-responders to antidepressant medication. The three-dimensional stereotactic surface projection (3D-SSP) method provided 3D-SSP images and relative metabolic values with minimal partial volume effects. The 3D-SSP score map showed decreased relative metabolism in the prefontal, cingulate and parietal regions in both hemispheres, and in the temporal region on the right, and increased relative metabolism in the occipital pole, vermis, cerebellum, dorsal-frontal, central convexity areas and basal ganglia in both hemispheres in patients compared with controls. The ratio of the parietal to occipital values in right plus left hemispheres was significantly decreased. Correlation coefficients of the anterior cingulate-primary sensorimotor, posterior cingulate-primary sensorimotor and occipital-media frontal in both hemispheres, of the frontal-primary sensorimotor, occipital-parahippocampal, primary visual-medial frontal and parahippocampal-amygdala in the right, and the frontal-vermis, parietal-thalamus, temporal-vermis, occipital-putamen, primary visual-putamen, thalamus-vermis and thalamus-cerebellum in the left were significantly different in patients compared with controls. Patients with late-onset depression who were treatment non-responders showed alterations not only in limbic-cortical circuits, but also in a wider network of thalamo-cortical circuits.     

Electroconvulsive therapy in patients with epilepsy

There are scant published data to guide the clinician about safe and effective use of electroconvulsive therapy (ECT) in epileptic patients who suffer from psychiatric disorders. In this report, we describe our experience treating 43 epileptic patients with ECT. Seven of the patients may have had spontaneous seizures during the course of treatments, although the possibility of pseudoseizures or nonictal phenomena seemed quite likely in several of these cases. For the majority of patients, adequate seizures could be obtained during ECT despite concomitant treatment with antiepileptic medications, although dose reductions were required in a few cases. Most patients enjoyed moderate to marked reductions in psychiatric symptoms with ECT, and one patient seemed to have a marked reduction in spontaneous seizure frequency for several weeks after completion of the ECT course. We conclude that most epileptic patients can be treated with ECT without dose adjustment in antiepileptic medications and provide general recommendations for safe use of ECT in this population.     

Electroconvulsive therapy in patients with multiple sclerosis

There are relatively few case reports of electroconvulsive therapy (ECT) in patients with multiple sclerosis. We present 3 such patients, all of whom received safe, effective ECT without evidence of acute neurological deterioration. We conclude that patients with multiple sclerosis being considered for ECT should have a thorough neurological evaluation, and the informed consent process should include discussion of the possibility of neurological deterioration. However, review of the literature and of our 3 cases does reveal that ECT can be used safely, at least in the short term. Long-term outcomes in such patients remain uncertain.     

Electroconvulsive therapy in patients with cavernous hemangiomas

Intracranial vascular malformations may potentially increase the risk of complications in electroconvulsive therapy (ECT), although there is only limited case report literature substantiating this. We describe 3 patients with cavernous hemangiomas who received safe, uncomplicated ECT. We provide recommendations for ECT practice in such patients.     

Electroconvulsive therapy modulates critical brain dynamics in major depressive disorder patients

BackgroundElectroconvulsive therapy (ECT) is widely considered as an effective and fast-acting option for treating patients with major depressive disorder (MDD). However, the neural basis underlying this powerful therapy remains uncertain. Recent studies have suggested that the healthy brain may operate near a critical state, which may reflect a balance between neuronal excitation and inhibition.ObjectiveIn the present study, we investigated whether there are any changes regarding criticality in MDD and, if so, whether ECT can reverse them. Critical dynamics analyses were performed on resting-state functional magnetic resonance imaging (rs-fMRI) data collected from 39 MDD patients and 38 healthy controls (HCs).ResultsWe found that compared with HCs, MDD patients, especially those who responded positively to ECT, tended to have smaller average avalanch sizes and lower branching ratios, suggesting a sub-critical state, at both the whole-brain and functional network levels. Importantly, ECT effectively corrected such anomalies, accompanied by enhanced degree centrality and functional connectivity of high-degree nodes located in the networks including the default-mode and the frontoparietal networks.ConclusionThese results indicate that ECT can modulate large-scale brain dynamics of MDD patients to be closer to criticality. Our study sheds new light on the pathology of MDD and the network mechanism by which ECT influences treatment.     

Electroconvulsive therapy in pregnant patients

Objectives

In this study, the aim was to evaluate the clinical characteristics of patients that received electroconvulsive therapy (ECT) during pregnancy due to psychiatric disorders, evaluate the safety and efficacy of ECT in pregnant women, and evaluate the overall status of mothers and babies during the postpartum period.

Methods

The study included 33 patients who were admitted as inpatients with the indication of ECT due to pregnancy and concurrent psychiatric disorders.

Results

Upon ECT administration, a complete response to treatment was seen in 84.21% of patients with major depression (n= 16), a partial response to treatment in 15.78% of patients (n= 3), a complete response to treatment in 91.66% of patients with bipolar disorder (n= 11), a partial response to treatment in 8.33% of the patients(n= 1), and a full response to treatment in 50% of patients with schizophrenia (n= 1) and a partial response to treatment in 50% of patients with schizophrenia (n= 1) were obtained. We had after birth information of 27 infants from total 33. It was learned that two of them had disease, one was stillbirth and 24 of them did not have any health problems.

Conclusions

ECT administration during pregnancy to treat psychiatric disorders was found to be an effective treatment method. No risk of preterm birth in mothers treated with ECT during pregnancy was detected.     

Electroconvulsive therapy in patients with vagus nerve stimulation

Numerous studies have demonstrated the safety and efficacy of electroconvulsive therapy (ECT) for various psychiatric conditions, and it has been approved by the Food and Drug Administration for the treatment of refractory depression. Recently, the Food and Drug Administration also approved vagus nerve stimulation as a treatment for chronic or recurrent depression. Although electrical stimulation is used for both ECT and vagus nerve stimulation, the mechanisms of their action are very different. The American Psychiatric Association task force identifies no absolute contraindications to the use of ECT. The authors present 2 interesting cases of successful ECT in combination with vagus nerve stimulator.     

Brain imaging in late-onset schizophrenia and related psychoses

In this article we review the published studies on brain imaging in late-life psychoses, and present data from our study of magnetic resonance (MR) imaging of the brain in late-onset schizophrenia (LOS). MR images were obtained in 11 patients with late-onset schizophrenia (LOS), nine patients with probable Alzheimer's disease (AD), and nine normal controls comparable in age, gender, and education. Two of the LOS patients were excluded from further analysis due to the presence of diagnosable organic pathology (i.e. Alzheimer's disease and presence of a subaracnoid cyst). The MR images were subjectively rated for both degree of ventricular enlargement (VE) and degree of abnormal white matter hyperintensities (WHM) by an experienced, board certified neuroradiologist in a blind manner. No significant differences were found among the groups on degree of abnormal WHM. MR images of AD patients had a significantly greater degree of VE than normal controls, with LOS patients being intermediate. Our data, for LOS and have evidence of non-specific abnormalities in brain morphology on MR imaging, yet do not have clinical or MR imaging evidence of a specific organic etiology for psychosis.     

Electroconvulsive therapy in old-old patients.

The authors compared falls, cardiovascular factors, confusion, gastrointestinal, pulmonary, and metabolic side effects for "old-old" (>75 years) patient groups treated with either electroconvulsive therapy (ECT) or pharmacotherapy. A subset of a pharmacotherapy patient group was selected to match for age, sex, and diagnosis in a case-control design. Side effects were recorded from each selected patient's medical record and compared between groups. Patients receiving ECT showed fewer cardiovascular and gastrointestinal side effects. Patients receiving ECT had longer lengths of stay and more favorable outcomes. Overall, there was a tendency for ECT to result in fewer side effects and better treatment outcomes. ECT appears to be relatively safe and more effective than pharmacotherapy for major depressive disorders in old-old patients.     

Electroconvulsive therapy treatment responsive multimodal brain networks

Electroconvulsive therapy is regarded as the most effective antidepressant treatment for severe and treatment‐resistant depressive episodes. Despite the efficacy of electroconvulsive therapy, the neurobiological underpinnings and mechanisms underlying electroconvulsive therapy induced antidepressant effects remain unclear. The objective of this investigation was to identify electroconvulsive therapy treatment responsive multimodal biomarkers with the 17‐item Hamilton Depression Rating Scale guided brain structure–function fusion in 118 patients with depressive episodes and 60 healthy controls. Results show that reduced fractional amplitude of low frequency fluctuations in the prefrontal cortex, insula and hippocampus, linked with increased gray matter volume in anterior cingulate, medial temporal cortex, insula, thalamus, caudate and hippocampus represent electroconvulsive therapy responsive covarying functional and structural brain networks. In addition, relative to nonresponders, responder‐specific electroconvulsive therapy related brain networks occur in frontal‐limbic network and are associated with successful therapeutic outcomes. Finally, electroconvulsive therapy responsive brain networks were unrelated to verbal declarative memory. Using a data‐driven, supervised‐learning method, we demonstrated that electroconvulsive therapy produces a remodeling of brain functional and structural covariance that was unique to antidepressant symptom response, but not linked to memory impairment.     

Meta-analysis of brain structural changes after electroconvulsive therapy in depression

BackgroundIncreases in the volume of the amygdala and hippocampus after electroconvulsive therapy (ECT) are among the most robust effects known to the brain-imaging field. Recent advances in the segmentation of substructures of these regions allow for novel insights on the relationship between brain structure and clinical outcomes of ECT.ObjectiveWe aimed to provide a comprehensive synthesis of evidence available on changes in brain structure after ECT, including recently published data on hippocampal subfields.MethodsA meta-analysis of published studies was carried out using random-effects models of standardized mean change of regional brain volumes measured with longitudinal magnetic resonance imaging of depressive patients before and after a series of ECT.ResultsData from 21 studies (543 depressed patients) were analysed, including 6 studies (118 patients) on hippocampal subfields. Meta-analyses could be carried out for seven brain regions for which data from at least three published studies was available. We observed increases in left and right hippocampi, amygdalae, cornua ammonis (CA) 1, CA 2/3, dentate gyri (DG) and subicula with standardized mean change scores ranging between 0.34 and 1.15. The model did not reveal significant volume increases in the caudate. Meta-regression indicated a negative relationship between the reported increases in the DG and relative symptom improvement (−0.27 (SE: 0.09) per 10%).ConclusionsECT is accompanied by significant volume increases in the bilateral hippocampus and amygdala that are not associated with treatment outcome. Among hippocampal subfields, the most robust volume increases after ECT were measured in the dentate gyrus. The indicated negative correlation of this effect with antidepressant efficacy warrants replication in data of individual patients.     

Electroconvulsive therapy in medication-nonresponsive patients with mixed mania and bipolar depression

BACKGROUND: The aim of this study was to investigate the effectiveness of electroconvulsive therapy (ECT) in medication-nonresponsive patients with mixed mania and bipolar depression. METHOD: Forty-one patients with mixed mania (DSM-IV diagnosis of bipolar I disorder, most recent episode mixed) and 23 patients with bipolar depression (DSM-IV diagnosis of bipolar I disorder, most recent episode depressed) consecutively assigned to ECT treatment were included in this study. Subjects were evaluated using the Montgomery-Asberg Depression Rating Scale (MADRS), the Brief Psychiatric Rating Scale (BPRS), and the Clinical Global Impressions-Severity of Illness scale (CGI-S). Assessments were carried out the day before starting ECT, 48 hours after completion of the third session (T1), and a week after the last session of ECT (T2). RESULTS: Both groups received an equal number of ECT sessions (mean +/- SD = 7.2 +/- 1.7 vs. 7.3 +/- 1.6). In both groups, within-group comparisons showed that there was a significant reduction in CGI-S score (mixed mania, p <.0001 at T1 and T2; bipolar depression, p < .01 at T1, p < .0001 at T2), MADRS total score (both groups, p < .0001 at T1 and T2), BPRS total score (mixed mania, p < .0001 at T1 and T2; bipolar depression, p < .001 at T1, p < .0001 at T2), and BPRS activation factor score (mixed mania, p < .0001 at T1 and T2; bipolar depression, NS at T1, p < .01 at T2). Between-group comparisons revealed that patients with mixed mania showed significantly greater decrease in MADRS score (p < .001) and a greater proportion of responders (CGI-S) than patients with bipolar depression at endpoint (56% [N = 23] vs. 26% [N = 6], p = .02). Patients with mixed mania showed a greater reduction in suicidality, as measured by MADRS score, than patients with bipolar depression (p < .02). CONCLUSION: In our study, ECT was associated with a substantial reduction in symptomatology, in both patients with mixed mania and those with bipolar depression. However, the mixed mania group exhibited a more rapid and marked response as well as a greater reduction in suicidal ideation. Response to ECT was not influenced by the presence of delusions.     

Structural changes in the brain in schizophrenia and affective psychoses]

Kraepelin (1896) and Bleuler (1916) were convinced that schizophrenia has an anatomical basis. Evidence is provided now by visualization methods made in vivo and stereometric methods used in neuropathology. Schizophrenia is associated with enlargement of the lateral and the third ventricle, widening of the sulci between gyri of the cerebral cortex, a decline of the weight of the brain, volume of the cerebral cortex and central gray matter. Histological examination reveals reduction of the parahippocampal gyrus thickness, changes in the hippocampus are controversial. Numerical atrophy of neurons was found in the mediodorsal nucleus of the thalamus, amygdaloid nucleus, prefrontal cortex, impaired pattern of neuronal modules were found in the g.cinguli. Some anatomical changes correlate with differences revealed by neuropsychiatric examination, positron emission tomography and examination of evoked potentials. Schizophrenia can be at least in some instances the consequence of developmental disorder of the brain. The problem of continuity of schizophrenia and affective psychoses is discussed.     

The late-onset psychoses. Clinical and diagnostic features

Psychoses of late onset are poorly understood due to a limited number of inconsistent studies. The authors conducted this study to determine the clinical characteristics of a clearly defined group of patients with onset of psychosis after age 65 years and to test the usefulness of DSM-III criteria in diagnosing the condition of these patients. Late-onset psychosis occurred in 8% of the patients admitted to the geropsychiatry unit during the study period. More than three quarters of these patients suffered from either an organic mental disorder or major affective disorder, the remainder having primary psychotic disorder. The diagnoses of the psychotic patients were much less reliable than those of a comparable group of nonpsychotic patients, with more than 5 times as many patients in the psychosis group changing diagnostic categories between the time of their admission and their discharge. DSM-III diagnostic criteria were not well suited for the categorization of many of these patients. For patients with primary psychotic disorder, the criteria artificially subdivided groups of similar patients. For patients with organic mental disorder, the criteria did not provide sufficient guidance for the diagnosis of psychosis in the presence of dementia. All three groups of patients responded to somatic therapies. A subgroup of patients with affective disorder improved without neuroleptic treatment, and several patients with primary psychotic disorder benefited from antidepressant treatment. These results highlight the difficulty inherent in the treatment of patients with late-onset psychosis. Further research is needed to develop adequate diagnostic criteria and to determine which patients will benefit from neuroleptic and/or antidepressant therapy.     

Electroconvulsive therapy is associated with lower readmission rates in patients with schizophrenia

BackgroundElectroconvulsive therapy is an important somatic treatment for severe mental disorders with established efficacy and safety. However, data on the relationship between ECT and the readmission rate of patients with schizophrenia are scarce. This study will explore the association between the administration of ECT and readmission rates using a machine learning method.MethodsInpatient medical records from the year of 2016 in one large psychiatric hospital in Beijing, China, were analyzed using a machine learning algorithm to determine the most important variables affecting readmission of patients with schizophrenia.ResultsThe medical records of 2131 inpatients with schizophrenia were reviewed. 1099 patients were followed up within 3 months of their index admission (642 ECT cases and 457 non-ECT cases) and 1032 patients were followed up within 6 months (596 ECT cases and 436 non-ECT cases) after discharge. The 3- and 6-month readmission rates in the ECT group (11.37% and 17.94%, respectively) were significantly lower than that of the patients who did not receive ECT (18.79% and 29.36%, respectively, both p < 0.001). The risk of readmission was significantly associated with male sex, older age, being married, having a lower income, a shorter inpatient length of stay, and receiving specific antipsychotic medications including olanzapine, paliperidone, clozapine, and haloperidol during the index admission. In the ECT group, patients who received 9 or more treatments were significantly less likely to be readmitted.ConclusionReceiving ECT may be associated with a lower risk of readmission in patients with schizophrenia.