Predictors of ECT Response- van Diermen et al. in J Clin Psych
Out on Pubmed, from researchers in Belgium and The Netherlands, is this study:Toward Targeted ECT: The Interdependence of Predictors of Treatment Response in Depression Further Explained.
J Clin Psychiatry. 2020 Dec 15;82(1):20m13287. doi: 10.4088/JCP.20m13287.PMID: 33326710
The abstract is copied below:
Objective: Several clinical variables assumed to be predictive of electroconvulsive therapy (ECT) outcome in major depressive disorder show substantial interrelations. The current study tries to disentangle this interdependence to distill the most important predictors of treatment success to help improve patient-treatment matching.
Methods: We constructed a conceptual framework of interdependence capturing age, episode duration, and treatment resistance, all variables associated with ECT outcome, and the clinical symptoms of what we coin core depression, ie, depression with psychomotor agitation, retardation, psychotic features, or a combination of the three. The model was validated in a sample of 73 patients with a major depressive episode according to DSM-5 treated twice weekly with ECT (August 2015-January 2018) using path analyses, with the size and direction of all direct and indirect paths being estimated using structural equation modeling. Reduction in Montgomery-Asberg Depression Rating Scale (MADRS) scores during treatment was the ECT outcome measure.
Results: The baseline presence of psychomotor agitation, retardation, and/or psychotic symptoms strongly correlated with beneficial ECT outcome (z = 0.84 [SE = 0.17]; P < .001), and the association between age and the effect of ECT appears to be mediated by their presence (z = 0.53 [SE = 0.18]; P = .004). There was no direct correlation between age and ECT response (P = .479), but there was for episode duration and ECT outcome (z = -0.38 [SE = 0.08]; P < .001).
Conclusions: ECT is a very effective treatment option for severe depressive disorder, especially for patients suffering from severe depression characterized by the presence of psychomotor agitation, psychomotor retardation, psychotic symptoms, or a combination of these 3 features, with the chance of a beneficial outcome being reduced in patients with a longer episode duration. Age may heretofore have been given too much weight in ECT decision making.
The paper is sophisticated and complex, yet clearly and cogently explained.
It makes intuitive sense that age itself is not a predictor of ECT response, but that the type of depression becomes more severe and "biological" with older age, as "the other things" (as JFK famously said in his "we go to the moon" speech), like personality disorder, fall by the wayside.
It is also very helpful to see that "treatment resistance", per se, is not a predictor of poor response, but more likely a proxy for other factors.
The authors' coining of the term "core depression," is helpful, despite the linguistic overlap with the "CORE" studies.
Figure 3 in the paper is a beautifully complex illustration of the "Path Model" and will make a fabulous PowerPoint slide for a presentation on depression.
This key paper is definitely worth a full and careful read (~25 minutes).
ReplyDeleteThe below comment is from Dr. Max Fink:
Depression and Melancholia
In assessing the Dutch-Belgian collaboration study of ECT in depression, van Dierman et al. offer to create a "core depression" responsive to ECT that is marked by "psychomotor retardation, agitation, psychotic features, or a combination of these features." For many centuries this syndrome has been described as "melancholia."
Within a decade after the induction of grand mal seizures to relieve schizophrenia in 1934, the Ziskinds described the remarkable benefits in relieving affective psychoses. In the 1970s, Bernard Carroll described a biological test, the Dexamethasone Suppression Test, that verified the diagnosis. The sad history of melancholia -- its rejection as a diagnostic entity by successive DSM commissions-- is well told by the medical historian Edward Shorter (Endocrine Psychiatry: Solving the Riddle of Melancholia, Oxford U Press, 2010). Rather than a drum roll for a new "core depression," these authors would do a greater service in bringing their cases into the melancholia tent.
For the biology of melancholia, readers are directed to the detailed text by Michael Alan Taylor : Melancholia: The Diagnosis, Pathophysiology, and Treatment of Depressive Illness. Cambridge U Press, 2006.
Max Fink
Thanks Charles for discussing our paper on your blog. It might be interesting to know that there was a lot of discussion about the term -core depression- that has never felt very right. In my doctoral thesis, the overarching term used to describe psychomotor retardation, agitation and psychotic symptoms was in fact -melancholic depression- instead of -core depression- we used in this paper. We completely agree with Max Fink that in fact these patients with core depression are our melancholic patients, but over the last decades melancholia has had different definititions which made us decide to us another term after all. We hope that despite the terminology issue our message is still clear, patients with agitation, retardation and/or psychotic symptoms are prone to respond to ECT.
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