Repetitive transcranial magnetic stimulation: Course and early prediction of response in depression.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is an effective treatment for depression, yet few studies have mapped the trajectories of symptom change over treatment. Tracking clinical response during early treatment may be helpful to predict outcome, particularly non-response. METHODS: We used naturalistic data (N = 117) to examine changes in the Daily Symptom Index (DI-5) scores of adult patients with unipolar or bipolar depression who underwent ≥16 treatment sessions of left dorsolateral prefrontal cortex rTMS at a private psychiatric facility in Western Australia, between 2016 and 2019. RESULTS: Two response trajectories were charted: non-response (N = 71, 61%) and response (N = 46, 39%). Both trajectories diverged at 99% confidence interval at session 10, which was used as the point to predict treatment response at session 20. The response group showed a reduction of 4.21 in the mean DI-5 score from baseline at session 10. On this basis, a 4-point reduction in the DI-5 score at session 10 was defined as predictor of responder status at session 20. If the improvement is < 4 points at session 10, the probability of non-response at session 20 is 75%. If the improvement is ≥ 4 points, the probability of response at session 20 is 66%. LIMITATIONS: The DI-5 scores were not examined beyond 20 treatment sessions, which may have shown delayed responders in the non-response group. CONCLUSIONS: In this study of depression response trajectories with rTMS treatment, prediction of response at session 20 can be made at session 10 of treatment. Further research is required to generalise the current findings.

The Clinical Alliance and Research in Electroconvulsive Therapy Network: An Australian Initiative for Improving Service Delivery of Electroconvulsive Therapy.

OBJECTIVE: There is currently substantial heterogeneity in electroconvulsive therapy (ECT) treatment methods between clinical settings. Understanding how this variation in clinical practice is related to treatment outcomes is essential for optimizing service delivery. The Clinical Alliance and Research in ECT Network is a clinical and research framework with the aims of improving clinical practice, enabling auditing and benchmarking, and facilitating the collection of naturalistic clinical data. METHODS: The network framework and clinical and treatment variables collected and rationale for the use of particular outcome measures are described. Survey results detailing the use of ECT across initial participating clinical centers were examined. RESULTS: The data are reported from 18 of 22 participating centers, the majority based in Australia. Melancholic unipolar depression was the most common clinical indication (78%). Right unilateral (44%) and bifrontal (39%) were the most commonly used electrode placements. Eighty one percent of the centers used individual seizure titration for initial dosing. CONCLUSIONS: There was substantial heterogeneity in the use of ECT between participating centers, indicating that the Network is representative of modern ECT practice. The Clinical Alliance and Research in ECT Network may therefore offer the opportunity to improve service delivery and facilitate the investigation of unresolved research questions pertaining to modern ECT practice.

Health Related Quality of Life after ECT for depression: A study exploring the role of different electrode-placements and pulse-widths.

INTRODUCTION: Prior research has shown large improvements in HRQOL after a course of ECT for depression. However, the effect of different types of ECT on HRQOL outcomes has not been explored. This is important due to the considerable range of ECT treatment modalities that currently exist in clinical practice. METHODS: HRQOL data from 355 depressed patients in three Australian clinical hospitals, who received ECT given with a range of treatment modalities (combinations of pulse-width and electrode-placement), were analysed. HRQOL was measured at baseline and after ECT, using the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF). The association between type of ECT and HRQOL after ECT was examined by regression analysis, controlling for variables that may affect HRQOL outcomes. RESULTS: There was a significant increase in HRQOL scores after ECT (p<0.0001; t=-23.4). The magnitude of change was large (54% increase, Cohen's d=1.43). Multiple regression analysis yielded a significant model (P<0.001, R2=0.18). Baseline HRQOL score (t=4.83; p<0.0001), age (t=2.75, p<0.01) and type of ECT received [Right Unilateral brief vs Bitemporal Ultrabrief (t=-2.99; p<0.01) and Right Unilateral brief vs Bifrontal Ultrabrief (t=-2.70; p<0.01)] were significant predictors of HRQOL after the ECT course. LIMITATIONS: Data was collected naturalistically from clinical services, thus ECT modality was not randomly assigned. Site could have confounded results. CONCLUSIONS: An acute course of ECT for depression produced statistically and clinically significant improvements in HRQOL. ECT treatment modality can substantially impact HRQOL outcomes, with the possibility of bilateral ultrabrief forms of ECT being less beneficial.

The comprehensive management of pregnant women with major mood disorders: a case study involving phenelzine, lithium, and quetiapine.

Pregnancy in women with severe mental illness (SMI) often bring added dimensions of complexity; considering that this group of women are choosing to have children at increasing rates, more highly complex cases will require management. A 31-year-old primigravida with a diagnosis of bipolar affective disorder was treated with an antidepressant, mood stabiliser and antipsychotic. This case discusses preconception counselling, pregnancy and labour management that resulted in the delivery of a 4,200 g baby at 39 weeks by emergency caesarian section. This case highlights the collaborative approach to care that is needed in this group of women and the need for increasing awareness and knowledge in health professionals. It follows the management from preconception through to the postpartum period.

Assessment of distress and burden in Australian private psychiatric inpatients.

OBJECTIVES: The study aimed to examine (i) the extent of the objective and subjective burden of care experienced by carers of individuals attending Australian private psychiatric hospitals, (ii) the degree to which a carer's distress was influenced by the patient's symptoms and the burden of care experienced. METHODS: A group of 135 inpatient-carer dyads, for inpatients who attended three Australian private psychiatric clinics, completed measures of distress (Depression Anxiety Stress Scales) and caregiver burden (Burden Assessment Scale; BAS) during an inpatient admission to a private psychiatric hospital. RESULTS: The level of burden reported by carers was comparable with overseas data. Factor analysis was used to identify the key dimensions of the BAS. The chief concerns of carers related to worries about the patient and disruption to activities. CONCLUSION: The burden experienced by carers needs to be recognized and addressed to ensure that they are able to continue to provide the care and support required by psychiatric inpatients. Present data are discussed in terms of the best way to support the carers of psychiatric inpatients.