Hair Cortisol, Depression, ECT
Methods: We were able to attain valid HCC from a scalp hair sample of sixty-two patients with a major depressive episode right before electroconvulsive therapy (ECT). HCC were our main biological outcome measure. We created subgroups using depression severity as defined by the Hamilton Depression Rating Scale, the presence/absence of psychotic symptoms, the presence of melancholia as defined by the CORE and catatonia as defined by the Bush-Francis Catatonia Rating Scale.
Results: Our analyses of the total group showed a median HCC of 4.4 pg/mg. We found patients with catatonia (N = 10) to have substantially higher median HCC (8.3 pg/mg) than patients without catatonia (3.8 pg/mg). Although presence of melancholia and depression severity were not significantly associated with HCC, more severe psychomotor agitation was associated with higher HCC. Pre-treatment HCC was not associated with ECT outcome.
Strengths and limitations: A complicating factor in interpretation of our results was the large variability in HCC. This could be related to potential confounders such as cardiometabolic and other comorbidities, that were however addressed to the extent possible.
Conclusions: HCC is a potential biomarker for MDD patients with severe agitation and/or catatonia. CLINICALTRIALS.GOV: Identifier: NCT02562846.
Keywords: ECT; Major depressive disorder; agitation; catatonia; electroconvulsive therapy; hair cortisol.
The investigation of cortisol and the HPA axis in mood disorders is like deja vu all over again or back to the future. By the early1980s the dexamethasone suppression test (DST) had almost become the first diagnostic lab test in psychiatry. But, despite the fact that dysregulation of the HPA axis was one of the most solidly established biological abnormalities in depression, the DST was killed. Not scientifically good enough? Not politically correct enough? The debate still rages...
But it is great to see renewed interest in the HPA axis and the new methods of measuring cortisol, both in hair and saliva. The hair samples as used in this study give a retrospective 3-month cumulative view of HPA axis activity, quite different from the immediate snapshot of the DST. Despite the umpteen potential confounders of measuring cortisol in hair, this is a very interesting study that deserves a careful, full read. The findings of 1) higher cortisol in depressed patients compared to historical controls 2) higher cortisol in a small subset of patients with catatonia and 3) higher cortisol in patients with more severe agitation are all interesting (#1 is well established) and worthy of further study and replication.
Dear Charles,
ReplyDeleteThanks a lot for discussing our most recent paper in your blog. With this article we indeed hope to boost research in this promising area of hair cortisol measurement - with potential applications and implications in depression treatment.
Best from Belgium,
Linda
The below comment is from Max Fink:
ReplyDeleteCortisol Hair Measures and Catatonia
This Dutch group's study revives interest in cortisol as a marker of severity of melancholia. Their second important contribution is the association of high cortisol levels with catatonia. In the 1970s Bernard Carroll and his colleagues described elevated cortisol tests in catatonia as well as melancholia.
The DST is a labor intensive and complex test. Although many of us saw and studied its levels as a marker of melancholia, the DSM-III committee and the APA 1986 Glassman Committee rejected the marker as too difficult, as not a marker of the diagnosis of MDD, and therefore best reserved for research. Their papal pronouncements assured insurers that the test could not be supported clinically. Research ended abruptly.
Cortisol tests offer gateways to understanding of catatonia as well as melancholia. The overlap of these syndromes is a present challenge. Both are disorders in mood, in motor activity, and are responsive to bilateral ECT.
The Dutch authors are to be commended for their revival of interest in the biology of both melancholia and catatonia.
Max Fink
Although pre-treatment HCC was not associated with ECT outcome, it would be nice to see whether the HCC value after teh conclusion of successful ECT predicts relapse.
ReplyDeleteAs Dr. Fink point out, the DST was rejected in part because the pure phenomenologists said that they could make a DSM diagnosis without the DST - which is true.
The real value of the DST, or now perhaps the HCC, might be in post-treatment planing after successful ECT ..... would persistently high HCC values post-ECT predict relapse? Or the need for continuation ECT?
Vaughn McCall