Difficult-to-treat-depression: ECT Data From a German Cohort

 Out on PubMed, from authors in Germany, is this study:

Risk Phenotypes, Comorbidities, Pharmacotherapy, and Electroconvulsive Therapy (ECT) in a Cohort with Difficult-to-Treat Depression in Comparison to an Unmedicated Control Group.

Maier HB, Borchert A, Neyazi A, Moschny N, Schülke R, Bundies GL, Folsche T, Gaspert A, Seifert J, Bleich S, Scherf-Clavel M, Unterecker S, Deckert J, Frieling H, Weber H.Pharmacopsychiatry. 2024 May 2. doi: 10.1055/a-2292-1438. Online ahead of print.PMID: 38698605 

The abstract is copied below:

Background: Approximately 15-25% of depressed patients suffer from difficult-to-treat depression (DTD). Patients with DTD require a thorough examination to avoid the oversight of treatable (psychiatric/somatic) comorbidities or (pseudo-)resistance to antidepressant drugs (ADs). Polymorphisms of the cytochrome P450 (CYP) enzymes 2D6 and 2C19, which play a major role in the metabolism of ADs, may contribute to resistance to ADs. Patients with DTD might benefit from electroconvulsive therapy (ECT).

Methods: We enrolled 109 patients with DTD and 29 untreated depressed controls (UDC). We assessed risk phenotypes, comorbidities, and treatment, including ECT. We also performed pharmacokinetic analyses of CYP2D6 and CYP2C19.

Results: DTD patients significantly more often suffered from comorbid psychiatric diseases, especially ICD-10: F40-F48 (DTD:40.4%, UDC:17.2%, OR 11.87, p=0.011) than UDC patients. DTD patients receiving ECT were more likely to achieve remission (37.7% vs. 11.8%, OR=3.96, p=0.023). Treatment with ADs did not differ between remitters and non-remitters. No significant differences were observed in the distribution of CYP2D6 and CYP2C19 variants between both groups.

Conclusion: Patients with DTD appear to experience comorbid neurotic stress and somatoform disorders (ICD-10: F40 - F48) more frequently. Therefore, a comprehensive differential diagnosis is crucial when patients do not respond sufficiently to antidepressant medication. Genotyping CYP2D6 and CYP2C19 should be considered.

The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

The article is here.

And from the text:

Patients receiving ECT in our cohort were more likely to achieve remission compared to those undergoing treatment as usual (i. e., pharmaco- and psychotherapy). This outcome is not surprising, considering that patients with DTD most likely underwent multiple treatment trials with ADs. Notably, our observed remission rates under ECT (37.7%) were lower than rates reported in the literature, where remission rates of up to 75% have been reported [52] [53]. The lower remission rates in our study could be attributed to the high prevalence of comorbidities. Further, we solely focused on remission and did not consider treatment response, which could also be a valid outcome criterion for patients enduring long-term illness. Nevertheless, our data unmistakably illustrates the advantages of utilizing ECT in the treatment of patients with DTD compared to conventional treatment methods.

So here we have a cohort of 61 patients who got ECT and did pretty well, despite being a less-than-ideal group for ECT response (too much psychiatric comorbidity).

I think we will continue to see the new treatment modalities nibble around the edges of populations considered for ECT, with some of the less ill patients (and those with comorbidities other than mood and psychotic disorders) showing some improvement, but ECT retaining its primacy and superiority for the most severely ill.