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The treatment of depressive phases of bipolar disorder is challenging. Electroconvulsive therapy (ECT) is generally considered to be the most effective treatment even if there are no randomized controlled trials (RCT) of ECT in bipolar depression. The safety of ECT is well documented, but there are some controversies as to the cognitive side effects.
To compare the effects and side effects of ECT with pharmacological treatment in treatment resistant bipolar depression. Cognitive changes during the treatment will be measured, as well as quality of life.
A prospective, randomised controlled multi-centre trial. 6- week acute treatment trial with 7 clinical assessments. Follow up visit at 26 weeks or until remission (max 52 weeks). A neuropsychological test battery designed to be sensitive to changes in cognitive function will be used.
Nine study centres across Norway, all acute psychiatric wards
132 patients aged 18 and over, who fulfil criteria for treatment resistant depression in bipolar disorder, MADRS score of at least 25 at baseline
Intervention group: 3 sessions per week for up to 6 weeks, total up to 18 sessions. Control group: algorithm-based pharmacological treatment as usual.
Six departments have included 43 patients since start in May 2008.
This study is the first randomized controlled trial that aims to investigate whether ECT is better than pharmacological treatment as usual in treatment resistant bipolar depression. Possible long lasting cognitive side effects will be evaluated. The study is investigator initiated, without support from industry.
There is a positive correlation between level of education and working function in the general population. Bipolar disorder (BD) is often associated with disability in social and working function. There is conflicting evidence considering educational achievements in BD patients.
Our aim was to investigate how education was related to social and occupational function in BD.
Patients with DSM-IV BD (N=257; 69.3% BD I, 25.7% BD II, 5.1% BD NOS, 51.4% females) were consecutively recruited from mental health clinics throughout Norway. The majority of patients were recruited when in-patients. About 1/2 had at least once experienced a psychotic episode. The BD sample was compared with a geographically matched reference sample from the general population (N=56.540) on levels of education, marital status, income, and disability benefits. Further analyses of association were carried out using logistic regression analyses.
A significantly higher proportion of subjects in the BD group than in the reference group was single, had low income, or was disabled. No between-group difference was found in educational level. In the reference group education was inversely correlated with the risk of being disabled, but no such relationship was found in the BD group. In BD patients rapid cycling and recurring depressive episodes were the only clinical characteristics associated with low educational level.
Despite similar levels of education, BD patients had lower socio-economic status than the general population, and no association was found between education and disability for BD patients.
Two common approaches to identify subgroups of patients with bipolar disorder are clustering methodology (mixture analysis) based on the age of onset, and a birth cohort analysis. This study investigates if a birth cohort effect will influence the results of clustering on the age of onset, using a large, international database.
The database includes 4037 patients with a diagnosis of bipolar I disorder, previously collected at 36 collection sites in 23 countries. Generalized estimating equations (GEE) were used to adjust the data for country median age, and in some models, birth cohort. Model-based clustering (mixture analysis) was then performed on the age of onset data using the residuals. Clinical variables in subgroups were compared.
There was a strong birth cohort effect. Without adjusting for the birth cohort, three subgroups were found by clustering. After adjusting for the birth cohort or when considering only those born after 1959, two subgroups were found. With results of either two or three subgroups, the youngest subgroup was more likely to have a family history of mood disorders and a first episode with depressed polarity. However, without adjusting for birth cohort (three subgroups), family history and polarity of the first episode could not be distinguished between the middle and oldest subgroups.
These results using international data confirm prior findings using single country data, that there are subgroups of bipolar I disorder based on the age of onset, and that there is a birth cohort effect. Including the birth cohort adjustment altered the number and characteristics of subgroups detected when clustering by age of onset. Further investigation is needed to determine if combining both approaches will identify subgroups that are more useful for research.
Electroconvulsive therapy (ECT) is a treatment alternative in bipolar disorder (BD) depression. Cognitive side effects are the major concern limiting its use.
We present data from the Norwegian randomized controlled trial of ECT in treatment resistant depression in bipolar disorder.
To compare effects on cognitive function of ECT or algorithm based pharmacological treatment at the end of a six-week acute, BD depression treatment trial.
Prospective, randomised controlled multi-centre, six-week acute treatment trial. Pre- and post-treatment assessments with the MATRICS Consensus Cognitive Battery (MCCB); a neuropsychological test battery designed to be sensitive to changes in cognitive function.
N = 51 patients ≥ 18 years fulfilling criteria for treatment resistant BD depression (MADRS score ≥ 25).
ECT group: Three sessions per week for up to six weeks, total up to 18 sessions, and right unilateral electrode placement. Algorithm-based pharmacological treatment group: Based on Goodwin & Jamison, 2007.
Both groups showed a net gain on MCCB scores without significant differences between the study groups. Mean change in MCCB composite T-score was 4.0 (5.7) in the ECT group and 2.7 (3.6) in the pharmacological group (F = 0.78, eta2 = 0.021, p = 0.383).
In treatment resistant BD depression ECT and algorithm-based pharmacological treatment have comparable effects on cognitive function assessed with the MATRICS.
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