Montgomery-Asberg Depression Rating Scale Scores Research Articles

Clinical differences between unipolar and bipolar depression

IntroductionEpidemiological studies indicate that the majority of patients with bipolar disorder are diagnosed many years later. Unipolar depression represents the most frequent misdiagnosis.ObjectivesThis study aimed to examine the symptom profiles of depressed patients in order to identify clinical specificities of bipolar depression.MethodsA total of 31 depressed patients were recruited from psychiatry outpatient department of Hedi Chaker university hospital in Sfax (Tunisia), during October and November 2016. Unipolar and bipolar patients were compared on a broad range of parameters, including sociodemographic and clinical characteristics. Depressive symptoms were rated using the Montgomery Asberg Depression Rating Scale (MADRS) and Bipolar Depression Rating Scale (BDRS).ResultsThe total sample comprised 31 patients with 16 men and 15 women. It involved 20 with unipolar depression and 11 with bipolar depression. Patients with bipolar depression had more family history of bipolar disorder (P = 0.037) and a triggering factor had been identified less often (P = 0.03). MADRS scores were similar in bipolar and unipolar patient (median score 28.22 versus 28.36; P = 0.964). BDRS scores were significantly higher in bipolar depressed patients (median score 33 versus 25; P = 0.01). The mixed subscale (item 16 to 20) scores were particularly higher (median 6 vs. 1.2; P ≤ 0.01) especially concerning irritability (P = 0.001). Increased motor drive (P = 0.004) and agitation (P = 0.008).ConclusionOur findings suggest that the presence of mixed symptoms is very important to recognize depressed patients as having a bipolar disorder. We also recommend routine use of the BDRS for patients presenting for treatment of depression.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Mechanism of coping in patients of alcohol dependence and its correlation with anxiety, depressive symptoms

Background: Alcohol use disorder is a common and challenging problem in India. In various studies the prevalence of co-morbid psychopathologies ranges from 15-70% including depression & anxiety disorders. Coping mechanisms of individual play vital role in case of developing alcohol dependence and various psychopathologies. A complex interaction of psychopathologies, coping skills, and alcohol use can influence the outcome of alcohol dependence. This study was undertaken with the aim of studying coping mechanism along with anxiety, depressive symptoms and their correlation in patients of alcohol dependence.Methods: This was a cross sectional study conducted in a tertiary government hospital. Institutional ethics committee approval obtained. 152 patients with the diagnosis of alcohol dependence (DSM IV TR) were screened for inclusion and exclusion criteria, out of which 60 patients were enrolled after taking written informed consent. Following scales were used for the study, mechanisms of coping scale (MOCS), Hamilton anxiety rating scale (HAM-A), Montgomery-Asberg depression rating scale (MADRS).Results: 32 patients had HAM-A score >17 suggestive of anxiety, similarly 40 patients had MADRS score >7 indicating depression. Problem focussed coping mechanism such as problem solving is associated with better outcome in terms of lesser anxiety and later age of first drink as well as developing dependence. Passivity, which is an emotion focussed coping mechanism, is associated with earlier first drink and higher depression score in patient suggesting poor outcome.Conclusions: Coping skills training should be incorporated in abstinence focused programs. Co-morbid psychopathologies like anxiety and depression are common in alcohol dependence individuals and thus, screening for these symptoms is essential for early interventions and better outcomes.

Repetitive Transcranial Magnetic Stimulation (5 and 10 Hz) With Modified Parameters in the Treatment of Resistant Unipolar and Bipolar Depression in a Private Practice Setting.

A limited number of studies have investigated the safety and efficacy of repetitive transcranial magnetic stimulation (rTMS) in the treatment of resistant depression in an outpatient private practice setting. We hypothesized that rTMS would be safe and effective in the treatment of resistant depression in a nonresearch population. We treated 22 outpatients with unipolar or bipolar depression who were experiencing a moderate to severe treatment-resistant major depressive episode (MDE). Treatment was based on a flexible dose schedule of either 5 Hz or 10 Hz rTMS applied over the left dorsolateral prefrontal cortex with modified parameters. Assessments were performed at baseline, then on a weekly basis. The patients had received at least 2 trials of antidepressant medication of an adequate dose and duration without satisfactory improvement in the index MDE. There was a significant change in Montgomery-Asberg Depression Rating Scale scores from baseline (29.14±5.85) to the end of week 4 (16.27±11.20); 50.00% (11/22) were responders and 40.9% (9/22) achieved remission. No major side effects were observed aside from mild headache in some patients. rTMS applied to the left dorsolateral prefrontal cortex was safe and effective in an important subset of outpatients with a moderate to severe MDE in a naturalistic setting. Outcomes demonstrated response rates similar to research populations. Further larger studies are needed to confirm the safety and effectiveness of rTMS in naturalistic conditions.

Prefrontal transcranial direct current stimulation (tDCS) as treatment for major depression: study design and methodology of a multicenter triple blind randomized placebo controlled trial (DepressionDC).

ClinicalTrials.gov Identifier NCT0253016.

P278 Transcranial direct current stimulation (tDCS) as treatment for major depression (DepressionDC) – Objectives and design of a prospective multicenter double blind randomized placebo controlled trial

Objectives Transcranial Direct Current Stimulation (tDCS) is considered as a putative therapeutical approach in Major Depressive Disorder (MDD) allowing for a non-invasive modulation of dysregulated frontal activity (Kalu et al., 2012). Findings of the largest 2 × 2 factorial randomized controlled trial (RCT) in MDD to date suggest an antidepressant effect of tDCS combined with a Selective Serotonin Reuptake Inhibitor (SSRI; Sertraline) that is superior to placebo treatment, tDCS alone and sertraline alone (Brunoni et al., 2013). With regard to a possible introduction of tDCS as treatment option for MDD a methodological sound replication trial is needed. Moreover, this study should overcome limitations of the previous trial (2 × 2 factorial design with small sample size; short treatment period; monocentre study). Methods In this randomized, placebo-controlled multicenter trial patients with MDD receive a 6-weeks treatment with prefrontal tDCS (anode over electrode position F3, cathode over F4, 5 sessions/week for 4 weeks followed by 2 sessions/week for 2 weeks, 30 min/day, 2 mA intensity) or sham tDCS (frequency and duration correspondent to active tDCS, ramp in and ramp out only without intermittent stimulation), as adjunctive treatment with a SSRI. Follow-up per patient is 3 and 6 months after the last tDCS session. Before, during, and after the treatment period different assessment scales will be conducted using a tablet-PC program which is specifically designed for this study to record neuropsychological features and the course of the individual symptomatology. Additionally, patients receive optional investigations including functional magnetic resonance imaging (fMRI) measuring functional and structural connectivity at baseline, after 6 weeks of tDCS treatment and 12 weeks after the last tDCS session. Discussion The purpose of this study is to explore the sustained efficacy and tolerability of repeated tDCS for the treatment of MDD and to assess the long-term efficacy of tDCS over 3–6 months. It is hypothesized that prefrontal tDCS in combination with an SSRI will provoke an antidepressant effect while antidepressant medication alone (sham tDCS) did not. This will be measured by the change from baseline in the Montgomery-Asberg Depression Rating Scale scores after 6 weeks of treatment.

Sertraline Versus Placebo in Patients with Major Depressive Disorder Undergoing Hemodialysis: A Randomized, Controlled Feasibility Trial.

Depression is common in patients on hemodialysis, but data on the benefits and risks of antidepressants in this setting are limited. We conducted a multicenter, randomized, double-blind, placebo-controlled trial of sertraline over 6 months in patients on hemodialysis with depression to determine study feasibility, safety, and effectiveness. Patients on hemodialysis at five United Kingdom renal centers completed the Beck Depression Inventory II. Those scoring ≥16 and not already on treatment for depression were invited to undergo diagnostic interview to confirm major depressive disorder. Eligible patients with major depressive disorder were randomized to receive the study medication-either sertraline or placebo. Outcomes included recruitment and dropout rates, change in the Montgomery-Asberg Depression Rating Scale and Beck Depression Inventory II, and qualitative information to guide design of a large-scale trial. In total, 709 patients were screened and enrolled between April of 2013 and October of 2014; 231 (32.6%) had Beck Depression Inventory II scores ≥16, and 68 (29%) of these were already receiving treatment for depression. Sixty-three underwent diagnostic interview, 37 were diagnosed with major depressive disorder, and 30 were randomized; 21 completed the trial: eight of 15 on sertraline and 13 of 15 on placebo (P=0.05). Dropouts due to adverse and serious adverse events were greater in the sertraline group. All occurred in the first 3 months. Over 6 months, depression scores improved in both groups. Beck Depression Inventory II score fell from 29.1±8.4 to 17.3±12.4 (P<0.001), and Montgomery-Asberg Depression Rating Scale score fell from 24.5±4.1 to 10.3±5.8 (P<0.001). There were no differences between sertraline and placebo groups. Although small, this is the largest randomized trial to date of antidepressant medication in patients on hemodialysis. Our results highlight recruitment issues. No benefit was observed, but trial size and the substantial dropout render consideration of benefit inconclusive. A definitive trial could use shorter follow-up and include depressed patients already taking antidepressants.

Reducing menopausal symptoms for women during the menopause transition using group education in a primary health care setting—a randomized controlled trial

ObjectivesWomen's physical and mental ill-health shows a marked increase during menopause, which usually occurs between 45 and 55 years of age. Mental illness and somatic symptoms are common causes of long-term sick leave. Women suffer from a lack of knowledge about the menopause transition and its associated symptoms. The aim of the study was to investigate whether group education for women in primary health care (PHC) about the menopause transition can improve their physical and mental ill-health. Study designThis randomized controlled study was conducted in PHC and aimed to evaluate a group education programme for women aged 45–55 years, around the menopause transition. A total of 131 women were randomized to group education or no intervention. The group intervention included two education sessions with topics related to menopause. They answered two questionnaires at baseline and at four-month follow-up: the Menopause Rating Scale (MRS) and the Montgomery-Asberg Depression Rating Scale (MADRS). Main outcome measureChange in MRS and MADRS scores over the four months. ResultsThe intervention group experienced a slight reduction in symptoms while the control group mostly experienced the opposite. ConclusionThis study showed that it was feasible to implement group education on menopause for women aged 45–55 years. The clinical trial registration numberNTC02852811

Agomelatine versus Sertraline: An Observational, Open-labeled and 12 Weeks Follow-up Study on Efficacy and Tolerability.

ObjectiveIn this open-labeled, 12 weeks follow-up study, we aimed to compare the efficacy and tolerability of agomelatine with sertralineMethodsThe outpatients of adult psychiatry clinic who have a new onset of depression and diagnosed as ‘major depressive episode’ by clinician according to the Diagnostic and Statistical Manual of Mental Disorders 4th edition and prescribed agomelatine (25 mg/day) or sertraline (50 mg/day) were included in the study.ResultsThe decline of mean Montgomery-Asberg Depression Rating Scale (MADRS) scores of agomelatine group was significantly higher than the sertraline group at the end of 2nd week; however, the difference was not significant at the end of 3 months. Mean Clinical Global Impression-Improvement scale (CGI-I) scores of agomelatine group was lower than sertraline group at first week. Mean CGI-Severity scale and CGI-I scores were favour to sertraline group at the end of the study. Remission rates were 46.7% for sertraline group and 33.3% for agomelatine group while response rates were 76.7% for both groups. Any patient from agomelatine group dropped-out due to adverse effects. The amount of side effects was also less with agomelatine.ConclusionAgomelatine has a rapid onset efficacy on depressive symptoms and this can be beneficial for some critical cases. Considering MADRS scores, agomelatine seems to have similar efficacy with sertraline but we also point the need for long term studies since CGI scores were favour to sertraline group at the end of the study. Agomelatine has a favourable tolerability profile both in terms of discontinuation and the amount of side effects compared to sertraline.

Expressed emotion in fibromyalgia: Contribution of spouses’ attitude and patients’ perception to clinical presentation of fibromyalgia

Objectives: Psychopathological symptoms presented by fibromyalgia patients include introversion, inability to reflect emotional needs, lack self-esteem, and inefficiency in social relationships. There are measures to assess the relationship of the expressed emotion of patients and spouses with severity of fibromyalgia syndrome (FS). The aim of this study to assess the effect of expressed emotion of patient (LEE) and her spouse (EE) on the severity of FS in women. Patients and Methods: 123 FS patients and 105 healthy controls enrolled for the study. In the study, fibromyalgia impact questionnaire (FIQ), Montgomery-Asberg Depression Rating Scale (MADRAS), and level of expressed emotion (LEE) and expressed emotion (EE) were recorded. Results: LEE in FS was significantly higher than that in healthy controls [15 (2-56) vs. 11 (3-38); p<0.05]. The EE in FS was significantly higher than that in healthy controls (14.2±4.3 vs. 12.4±4.2; p<0.05). The FIQ score had mild correlations with LEE and EE, place of residence, and family history of FS (r=0241, r=0183, 0.214, and 0.203; respectively) but not with education status, family type, MADRAS score, number of tender points, and duration of FS (p>0.05). After linear hierarchical regression analysis was done to determine to the interaction of EE on the relationship of LEE and FIQ scores, there was no statically significant interaction of EE on the relationship of LEE and FIQ scores (p>0.05). Conclusion: The findings of this study support the value of assessment of EE from the perspective of patients and their spouses during the management of FS. To improve the psychological function of FS patients, in clinical practice, considering the role of spouses may provide an important advantage and increase the success of management of FS.

L-Methylfolate For Bipolar I depressive episodes: An open trial proof-of-concept registry

BackgroundL-methylfolate is a compelling candidate to treat bipolar I major depressive episodes. While approved as an adjunct for unipolar major depressive disorder, no studies have been done to assess the tolerability, safety, and efficacy of L-methylfolate for bipolar depression. As a first step, we developed a registry of bipolar patients treated with L-methylfolate to examine tolerability and outcomes. MethodsSubjects (N=10) received treatment as usual plus daily L-methylfolate 15mg for 6 weeks in this open-label registry. Depressive symptoms were assessed with the Montgomery Asberg Depression Rating Scale (MADRS) and manic symptoms with the Young Mania Rating Scale (YMRS). Effect size was measured with Cohen's d to provide an estimate of potential efficacy. ResultsThe pre-treatment mean (SD) MADRS score was 23.4 (4.34); the post-treatment score was 13.9 (8.24). Cohen's d was 1.19. At post-treatment, 6/10 patients had at least 50% MADRS improvement, and 4/10 patients exhibited remission with MADRS≤10. The pre-treatment YMRS score was 3.2 (3.0); the post-treatment score was 2.7 (5.2). Cohen's d was 0.17. LimitationsThis registry was a small open-label clinical trial for a fluctuating disorder. We cannot rule out that our results are due to regression to the mean. A controlled trial is warranted. ConclusionsThis first proof-of-concept open registry suggests that L-methylfolate in combination with treatment as usual has potential to treat bipolar depression.

Randomized, proof-of-concept trial of low dose naltrexone for patients with breakthrough symptoms of major depressive disorder on antidepressants

BackgroundGiven the proposed dopaminergic mechanism of low-dose naltrexone (LDN), we examined its efficacy as augmentation for depressive breakthrough on pro-dopaminergic antidepressant regimens. Methods12 adults (67% female, mean age = 45±12) with recurrent DSM-IV major depressive disorder (MDD) on dopaminergic antidepressant regimens (stimulants, dopamine agonists, bupropion [≥300mg/day], aripiprazole [≤2.5mg/day], or sertraline [≥150mg/day]) were randomized to naltrexone 1mg b.i.d. (n=6) or placebo (n=6) augmentation for 3 weeks. ResultsAll subjects completed the trial. Hamilton Depression Rating Scale (HAM-D-17) scores (primary outcome measure) decreased from 21.2±2.0 to 11.7±7.7 for LDN, from 23.7±2.3 to 17.8±5.9 for placebo (Cohen's d=0.62; p=0.3 between treatment groups). HAM-D-28 scores decreased from 26.2±4.0 to 12.0±9.8 for LDN, from 26.3±2.6 to 19.8±6.6 for placebo (d=1.15; p=0.097). Montgomery-Asberg Depression Rating Scale (MADRS-10 item) scores decreased from 30.4±4.9 to 12.2±8.4 for LDN, from 30.7±4.3 to 22.8±8.5) for placebo (d=1.45; p=0.035). MADRS-15 item scores decreased from 36.6±6.2 to 13.2±8.8 for LDN, from 36.7±4.2 to 26.0±10.0 for placebo (d=1.49; p=0.035). Clinical Global Improvement Scale-Severity (CGI-S) scores decreased from 4.3±0.5 to 3.0±1.1 for LDN, from 4.3±0.5 to 4.0±0.6 for placebo (d=1.22; p=0.064). LimitationsSmall study; restrictions on allowed antidepressants. ConclusionLDN augmentation showed some benefit for MDD relapse on dopaminergic agents. Confirmation in larger studies is needed.

Ineffectiveness of nicotinic acetylcholine receptor antagonists for treatment-resistant depression: a meta-analysis.

Emerging preclinical and clinical evidences suggest a potential role of nicotinic acetylcholine receptors in the pathophysiology of depression. Several clinical trials have investigated the efficacy of nicotinic acetylcholine receptor antagonists in treatment-resistant depression. We carried out this meta-analysis to investigate whether nicotinic acetylcholine receptor antagonists significantly improve symptoms in patients with major depressive disorder who have an inadequate response to standard antidepressant therapy. A comprehensive literature search identified six randomized-controlled trials. These six trials, which included 2067 participants, were pooled for this meta-analysis using a random-effects model. Nicotinic acetylcholine receptor antagonists failed to show superior efficacy compared with placebo in terms of the mean change in the Montgomery-Asberg Depression Rating Scale score [mean difference=-0.12 (95% confidence interval (CI)=-0.96 to 0.71]; response rate [risk ratio=0.92 (95% CI=0.83-1.02)]; and remission rate [risk ratio=1.01 (95% CI=0.83-1.23)]. This meta-analysis failed to confirm preliminary positive evidence for the efficacy of nicotinic acetylcholine receptor antagonists in treatment-resistant depression. Further studies investigating the efficacy of various alternative treatment strategies for treatment-resistant depression will help clinicians to better understand and choose better treatment options for these populations.

Executive Dysfunction Predicts Treatment Response to Neuroplasticity-Based Computerized Cognitive Remediation (nCCR-GD) in Elderly Patients with Major Depression

Executive dysfunction (ED) is a predictor of poor treatment response of late-life depression to pharmacotherapy. In response to the consistency of these findings, we designed neuroplasticity-based computerized cognitive remediation (nCCR-GD) intervention to target and improve ED in patients who failed to remit with antidepressant treatment. This study tests the hypothesis that ED at baseline will predict favorable treatment response to nCCR-GD. 11 elderly patients with treatment-resistant major depression were treated with a 30-hour, 4-week, unblinded, nCCR-GD treatment trial. Neuropsychological performance was assessed at baseline and after treatment ceased. ED at baseline was associated with greater reduction in Montgomery-Asberg Depression Rating Scale score over the 4-week treatment β = -0.74, F(2,8) = 10.85, p = 0.009, R(2) = 0.55. ED predicts favorable treatment response to nCCR-GD in older adults suffering from major depression resistant to antidepressants. This finding is opposed to studies testing pharmacotherapy where ED predicts poorer treatment response.

Participant Characteristics as Modifiers of Response to N-Acetyl Cysteine (NAC) in Obsessive-Compulsive Disorder

We previously reported on a 16-week, double-blind, randomized placebo-controlled trial (RCT) using 3 grams per day of N-acetyl cysteine (NAC) (1.5 grams twice per day) in 44 participants (aged 18–70) with DSM-5-diagnosed obsessive-compulsive disorder (OCD). We now report on an analysis of age, severity and duration of illness, OCD presentation type, baseline anxiety and depression scores, as well as the use of antidepressant medications as potentially modifying factors. Results revealed a significant effect ( p = .037) for younger participants (under mean age of 34) responding to NAC. This remained significant using OCD severity as a covariate ( p = .044). For those under 34 years of age with less than 17 years of OCD duration, this was also significant ( p = .037). Regression analysis within the NAC treatment group also revealed that duration of OCD presentation was a significant predictor of Yale-Brown Obsessive Compulsive Scale (YBOCS) change at study endpoint ( p = .019), whereas baseline Montgomery–Asberg Depression Rating Scale scores were also a trend-level predictor ( p = .060) of YBOCS change in the NAC group.

Assessing the Association Between Electrical Stimulation Dose, Subsequent Cognitive Function and Depression Severity in Patients Receiving Bilateral Electroconvulsive Therapy for Major Depressive Disorder

To assess the relationship between electrical stimulation administered to patients undergoing bilateral electroconvulsive therapy (ECT) and subsequent measures of cognitive function and depression severity. Stimulus dose titrated patients receiving bilateral ECT were assessed with the Cambridge Neuropsychological Test Automated Battery (CANTAB) Spatial Recognition Memory test and Montgomery Asberg Depression Rating Scale (MADRS) at baseline, after 4 ECT treatments and on course completion. Changes in CANTAB and MADRS scores were assessed in relation to electrical dosage, initial stimulus dose, and demographic variables using linear mixed models. Data pertained to 143 patients (mean age, 56.85 [SD, 14.94], 43% male). Median change in CANTAB score was -10% (-20% to 5%) after 4 ECT treatments and -10% (-20% to 5%) at course completion. Median change in MADRS score was -22 (-33 to -13) after 4 ECT treatments and -14 (-25 to -7) at course completion. Electrical dosage had no effect on CANTAB or MADRS change scores either after 4 treatments or course completion. Improvement in CANTAB score at end of course was associated with female sex (P < 0.05), higher intelligence quotient (P = 0.01), and age. After 4 treatments, improvement in CANTAB score was associated with younger age (P < 0.001) and higher intelligence quotient (P < 0.01). Improved MADRS score at course completion was associated with older age (P < 0.001 at end of course and after 4 treatments). Electroconvulsive therapy has significant antidepressant and cognitive effects which are not associated with the total electrical dose administered. Other, unalterable variables, such as age and sex, have an influence on these effects.

Relationship between Erythrocyte Fatty Acid Composition and Psychopathology in the Vienna Omega-3 Study.

This study investigated the relationship between erythrocyte membrane fatty acid (FA) levels and the severity of symptoms of individuals at ultra-high risk (UHR) for psychosis. Subjects of the present study consisted of 80 neuroleptic-naïve UHR patients. Partial correlation coefficients were calculated between baseline erythrocyte membrane FA levels, measured by gas chromatography, and scores on the Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning Scale, and Montgomery–Asberg Depression Rating Scale (MADRS) after controlling for age, sex, smoking and cannabis use. Subjects were divided into three groups according to the predominance of positive or negative symptoms based on PANSS subscale scores; membrane FA levels in the three groups were then compared. More severe negative symptoms measured by PANSS were negatively correlated with two saturated FAs (myristic and margaric acids), one ω-9 monounsaturated FA (MUFA; nervonic acid), and one ω-3 polyunsaturated FA (PUFA; docosapentaenoic acid), and were positively correlated with two ω-9 MUFAs (eicosenoic and erucic acids) and two ω-6 PUFAs (γ-linolenic and docosadienoic acids). More severe positive symptoms measured by PANSS were correlated only with nervonic acid. No associations were observed between FAs and MADRS scores. In subjects with predominant negative symptoms, the sum of the ω-9 MUFAs and the ω-6:ω-3 FA ratio were both significantly higher than in those with predominant positive symptoms, whereas the sum of ω-3 PUFAs was significantly lower. In conclusion, abnormalities in FA metabolism may contribute to the neurobiology of psychopathology in UHR individuals. In particular, membrane FA alterations may play a role in negative symptoms, which are primary psychopathological manifestations of schizophrenia-related disability.

Nicotinic acetylcholine receptor antagonists for treatment-resistant depression: A meta-analysis

ObjectiveEmerging preclinical and clinical evidence suggests a potential role of nicotinic acetylcholine receptors in the pathophysiology of depression. Several clinical trials have investigated the efficacy of nicotinic acetylcholine receptor antagonists in treatment-resistant depression. We performed this meta-analysis to investigate whether nicotinic acetylcholine receptor antagonists significantly improve symptoms in patients with major depressive disorder who have an inadequate response to standard antidepressant therapy.MethodsA comprehensive literature search identified 6 randomized controlled trials. These 6 trials, which included 2067 participants, were pooled for this meta-analysis using a random-effects model.ResultsNicotinic acetylcholine receptor antagonists failed to show superior efficacy compared to placebo in terms of the mean change in the Montgomery-Asberg Depression Rating Scale (MADRS) score [mean difference = –0.12 (95% CI = –0.96 to 0.71); response rate (risk ratio [RR] = 0.92 (95% CI = 0.83 to 1.02)); and remission rate [RR] = 1.01 (95% CI= 0.83 to 1.23)].ConclusionThis meta-analysis failed to confirm preliminary positive evidence for the efficacy of nicotinic acetylcholine receptor antagonists in treatment-resistant depression. Further studies investigating the efficacy of various alternative treatment strategies for treatment-resistant depression will help clinicians to better understand and choose better treatment options for these populations.Disclosure of interestThe authors have not supplied their declaration of competing interest.

ID 8 – Repetitive transcranial magnetic stimulation in chronic anxiety and depression

Objective Presenting the case of a gentleman with chronic treatment resistant depression (TRD) and social anxiety disorder, who first failed ECT and left sided high frequency repetitive transcranial magnetic stimulation (rTMS) but then responded to right sided low frequency rTMS in order to highlight the therapeutic potential of right sided rTMS for the treatment of TRD with co-morbid anxiety. Methods 44 year old married mixed race male with primary symptoms of chronic sadness, deep sense of worthlessness and hopelessness, irritability, anergia, poor concentration, intermittent suicidal ideation and anxiety. Since the mid 1990s, he’s had adequate trials of multiple psychotropic medications and psychotherapy. Twenty sessions of bilateral ECT offered no therapeutic benefit. He thus began left unilateral, high frequency (10 Hz) rTMS. Results Using the Montgomery–Asberg Depression Rating Scale (MADRS), his initial score was 28. He received 32 left sided treatments, but failed to respond. He was switched to right sided rTMS and after 20 sessions his MADRS score decreased to 9. He has been continued on maintenance rTMS therapy monthly and remains in remission. Conclusion This case illustrates that if left sided high frequency rTMS proves ineffective, then right sided, low frequency treatment should be considered in patients suffering with chronic depression and anxiety.

Anticonvulsant Mechanisms of Electroconvulsive Therapy and Relation to Therapeutic Efficacy.

Electroconvulsive therapy (ECT) is held to confer anticonvulsant effects, although the role of rise in seizure threshold upon clinical effect is uncertain. This study investigated the relationship in a large, consecutive, retrospective sample of patients receiving ECT in Aberdeen. We have tested the hypotheses of previous authors to further examine the relationship between seizure and therapeutic effect as well as discuss the potential underlying neurobiological mechanisms. All patients receiving ECT at the Royal Cornhill Hospital between 2000 and the end of 2008 were identified from the Scottish ECT Accreditation Network. Electroconvulsive therapy was administered twice weekly with a bifrontotemporal electrode placement using routine dosage schedules. Data were gathered from the Scottish ECT Accreditation Network and case notes regarding ECT course and clinical effect. The seizure threshold increased in 219 (94.4%) patients, stayed the same in 13 (5.6%) patients, and decreased in 0 patient (n = 232). No significant relationship was present between change in seizure threshold and change in Montgomery-Asberg Depression Rating Scale score (P = 0.39; Kendall τ b r = 0.047; n = 182), although responders did display greater increase in seizure threshold than nonresponders. Electroconvulsive therapy confers anticonvulsant effects in a consecutive sample of real-life patients. Neither initial seizure threshold nor magnitude of seizure threshold increase is a predictor of clinical response to ECT. A rise in seizure threshold is not essential for therapeutic effect but may represent an important marker of underlying neuronal state. The evidence reviewed in this article supports a link between neuroplastic effects of ECT and the evidenced rise in seizure threshold.

Symptom severity of bipolar disorder during the menopausal transition

BackgroundLittle is known about the mood symptom experience of women with bipolar disorder during the menopausal transition (MT). Yet times of rapid hormonal decline, such as the postpartum, are associated with increased risk of severe mood episodes in bipolar disorder, and the MT is a time of increased risk for unipolar depression in women with or without a history of depression.MethodsEnrollment included 56 women 40–60 years old diagnosed in the bipolar spectrum who were experiencing menopausal symptoms or were up to 5 years since their final menstrual period. Menopausal stages included early menopause, late menopause, or early postmenopause based on standardized criteria. Observational, prospective standardized mood symptom and reproductive hormone assessments were completed periodically. Concurrent menopausal symptoms as well as history of mood exacerbation during past reproductive events were assessed.ResultsForty-four women were included in the main analysis. The average Montgomery-Asberg Depression Rating Scale (MADRS) score was 4.43 points higher in the late transition/early postmenopausal stage women (n = 29) compared to the early menopausal stage women (n = 15) (±SE 2.14; p = 0.039), corresponding to a roughly 10 % higher score (range 0–40) in the late/post stage across all study visits. Results were similar for the Young Mania Rating Scale (YMRS), where the average score was 2.54 points higher in the late/early postmenopausal stage women compared to the early menopausal stage women (±SE 1.15; p = 0.027), also roughly 10 % higher (range 0–26). Estradiol and follicle-stimulating hormone (FSH) absolute levels as well as between-visit change in levels were not notably associated with YMRS or MADRS during study observation. Total Greene Climacteric Symptom (menopausal symptom) score was significantly associated with MADRS but not YMRS. History of mood exacerbation premenstrually and/or postpartum was not significantly associated with YMRS or MADRS severity during the MT.ConclusionsThese results support the theory that times of increased reproductive hormonal changes, such as the late MT and early postmenopause, here compared to early MT, are associated with greater mood symptom severity in bipolar spectrum women. Nonetheless, absolute or change in FSH and estradiol levels were not significantly associated with depression or mood elevation severity.