Electroconvulsive therapy response and remission in moderate to severe depressive illness: a decade of national Scottish data.

BACKGROUND: Despite strong evidence of efficacy of electroconvulsive therapy (ECT) in the treatment of depression, no sensitive and specific predictors of ECT response have been identified. Previous meta-analyses have suggested some pre-treatment associations with response at a population level. AIMS: Using 10 years (2009-2018) of routinely collected Scottish data of people with moderate to severe depression (n = 2074) receiving ECT we tested two hypotheses: (a) that there were significant group-level associations between post-ECT clinical outcomes and pre-ECT clinical variables and (b) that it was possible to develop a method for predicting illness remission for individual patients using machine learning. METHOD: Data were analysed on a group level using descriptive statistics and association analyses as well as using individual patient prediction with machine learning methodologies, including cross-validation. RESULTS: ECT is highly effective for moderate to severe depression, with a response rate of 73% and remission rate of 51%. ECT response is associated with older age, psychotic symptoms, necessity for urgent intervention, severe distress, psychomotor retardation, previous good response, lack of medication resistance, and consent status. Remission has the same associations except for necessity for urgent intervention and, in addition, history of recurrent depression and low suicide risk. It is possible to predict remission with ECT with an accuracy of 61%. CONCLUSIONS: Pre-ECT clinical variables are associated with both response and remission and can help predict individual response to ECT. This predictive tool could inform shared decision-making, prevent the unnecessary use of ECT when it is unlikely to be beneficial and ensure prompt use of ECT when it is likely to be effective.

Fronto-medial electrode placement for electroconvulsive treatment of depression.

Electroconvulsive therapy (ECT) is the most effective treatment for severe treatment-resistant depression but concern about cognitive side-effects, particularly memory loss, limits its use. Recent observational studies on large groups of patients who have received ECT report that cognitive side-effects were associated with electric field (EF) induced increases in hippocampal volume, whereas therapeutic efficacy was associated with EF induced increases in sagittal brain structures. The aim in the present study was to determine whether a novel fronto-medial (FM) ECT electrode placement would minimize electric fields in bilateral hippocampi (HIP) whilst maximizing electric fields in dorsal sagittal cortical regions. An anatomically detailed computational head model was used with finite element analysis, to calculate ECT-induced electric fields in specific brain regions identified by translational neuroimaging studies of treatment-resistant depressive illness, for a range of electrode placements. As hypothesized, compared to traditional bitemporal (BT) electrode placement, a specific FM electrode placement reduced bilateral hippocampal electric fields two-to-three-fold, whilst the electric fields in the dorsal anterior cingulate (dAC) were increased by approximately the same amount. We highlight the clinical relevance of this specific FM electrode placement for ECT, which may significantly reduce cognitive and non-cognitive side-effects and suggest a clinical trial is indicated.

Survey of Core Trainees' Confidence in Electroconvulsive Therapy.

OBJECTIVES: The objective of the survey was to assess confidence in electroconvulsive therapy (ECT) in core psychiatry trainees across Scotland, looking at both theoretical and practical aspects of ECT. METHODS: A link to a 14-item electronic questionnaire was distributed to core trainees via deanery administrators. Most questions were based on the Royal College of Psychiatry's ECT guidelines. RESULTS: A total of 85 responses were analyzed from trainees at all 3 levels of core training and from all health boards across Scotland. Almost 90% of trainees felt that their ECT training was sufficient, with more senior trainees rating their training better than those in the first year of training. Trainees who had theoretical teaching before their practical sessions rated their training better than those with purely observational training. Most trainees felt confident delivering ECT under supervision, and nearly 75% of trainees felt confident preparing a patient for ECT. The areas in which trainees felt least confident were in practical aspects such as dosing protocols and electroencephalogram interpretation. CONCLUSIONS: While ECT training and trainee confidence in delivering ECT were generally good, there are variations in trainees' experience that could be addressed by having a standardized ECT training, including theoretical teaching and practical competencies, in line with current guidelines. Ideally, evidence of meeting the Royal College recommendations for ECT competencies could be made a compulsory aspect of core training in the United Kingdom.

Transition to schizophrenia in acute and transient psychotic disorders.

BACKGROUND: The diagnostic category of acute and transient psychotic disorders (ATPD) was introduced in ICD-10. Subsequent studies have called into question its validity and reliability. AIMS: To determine the pattern of diagnostic revision to schizophrenia in first-ever diagnosed ATPD. METHOD: Using data drawn from the Scottish Morbidity Record, we estimated incidence and diagnostic change in first-ever diagnosed ATPD in Scottish hospitals between January 1997 and December 2010 (n = 2923). RESULTS: The average incidence of ATPD was 4.1 per 100 000 population per year. Diagnostic stability was estimated at 53.9% over an average of approximately 4 years of observation. The most common diagnostic shift was to schizophrenia (12.6%), over an average of 1.7 years. Estimates of the transition risks for schizophrenia were 80% at 2.8 years and 90% at 4.6 years. Longer first admission to hospital, younger age at onset and male gender were associated with increased risk and earlier development of schizophrenia. CONCLUSIONS: Routinely collected data suggest that approximately one in eight individuals with first-ever diagnosed ATPD will develop schizophrenia within 3-5 years. Those at high risk of transition may benefit from monitoring for possible diagnostic change.

Cannabis as a risk factor for psychosis: systematic review.

Various lines of evidence suggest an association between cannabis and psychosis. Five years ago, the only significant case-control study addressing this question was the Swedish Conscript Cohort. Within the last few years, other studies have emerged, allowing the evidence for cannabis as a risk factor to be more systematically reviewed and assessed. Using specific search criteria on Embase, PsychINFO and Medline, all studies examining cannabis as an independent risk factor for schizophrenia, psychosis or psychotic symptoms, published between January 1966 and January 2004, were examined. Additional studies were also reviewed from references found in retrieved articles, reviews, and a cited reference search (ISI-Web of Science). Studies selected for meta-analysis included: (i) case-control studies where exposure to cannabis preceded the onset of schizophrenia or schizophrenia-like psychosis and (ii) cohort studies of healthy individuals recruited before the median age of illness onset, with cannabis exposure determined prospectively and blind to eventual diagnosis. Studies of psychotic symptoms were also tabulated for further discussion. Eleven studies were identified examining the relationship between cannabis use and psychosis. Seven were included in the meta-analysis, with a derived odds ratio (fixed effects) of 2-9 (95 % confidence interval = 2.4-3.6). No evidence of publication bias or heterogeneity was found. Early use of cannabis did appear to increase the risk of psychosis. For psychotic symptoms, a dose-related effect of cannabis use was seen, with vulnerable groups including individuals who used cannabis during adolescence, those who had previously experienced psychotic symptoms, and those at high genetic risk of developing schizophrenia. In conclusion, the available evidence supports the hypothesis that cannabis is an independent risk factor, both for psychosis and the development of psychotic symptoms. Addressing cannabis use, particularly in vulnerable populations, is likely to have beneficial effects on psychiatric morbidity.

Reduced binocular depth inversion in regular cannabis users.

The binocular depth inversion illusion (BDII) has been shown to be a sensitive measure of impaired visual information processing under conditions including cannabinoid-intoxicated states, alcohol withdrawal, sleep deprivation, and in patients with positive symptoms of schizophrenia. This study assessed whether the BDII could detect subtle cognitive impairment due to regular cannabis use by comparing 10 regular cannabis users and 10 healthy controls from the same community sources, matched for age, sex, and premorbid IQ. Subjects were also compared on measures of executive functioning, memory, and personality. Regular cannabis users were found to have significantly higher BDII scores for inverted images. This was not due to a problem in the primary processing of visual information, as there was no significant difference between the groups for depth perception of normal images. There was no relationship between BDII scores for inverted images and time since last dose, suggesting that the measured impairment of BDII more closely reflected chronic than acute effects of regular cannabis use. There were no significant differences between the groups for other neuropsychological measures of memory or executive function. A positive relationship was found between EPQ-R-psychoticism and cannabis, tobacco, and alcohol use. Cannabis users also used significantly larger amounts of alcohol. However, no relationship was found between BDII scores and drug use other than cannabis or psychoticism. Compared to the other neuropsychological tests used, the BDII appears to be a more sensitive tool for the detection of subtle impairments in visual information processing related to chronic cannabis use.