Surgeon Gen Report
The Surgeon General’s Report on Mental Illness
Etiology of Mood Disorders
The etiology of depression, the mood disorder most frequently studied, is far from ideally understood. Many cases of depression are triggered by stressful life events, yet not everyone becomes depressed under such circumstances. The intensity and duration of these events, as well as each individual’s genetic endowment, coping skills and reaction, and social support network contribute to the likelihood of depression. That is why depression and many other mental disorders are broadly described as the product of a complex interaction between biological and psychosocial factors (see Chapter 2). The relative importance of biological and psychosocial factors may vary across individuals and across different types of depression. This section of the chapter describes the biological, genetic, and psychosocial factors-such as cognition, personality, and gender-that correlate with, or predispose to, depression. The discussion of genetic factors also incorporates the latest findings about bipolar disorder. Genes are implicated even more strongly in bipolar disorder than they are in major depression, galvanizing a worldwide search to identify chromosomal regions where genes may be located and ultimately to pinpoint the genes themselves (NIMH, 1998).
Biologic Factors in Depression Much of the scientific effort expended over the past 40 years on the study of depression has been devoted to the search for biologic alterations in brain function. From the beginning, it has been recognized that the clinical heterogeneity of depression disorders may preclude the possibility of finding a single defect. Researchers have detected abnormal concentrations of many neurotransmitters and their metabolites in urine, plasma, and cerebrospinal fluid in subgroups of patients (Thase & Howland, 1995); dysregulation of the HPA axis (Thase & Howland, 1995); elevated levels of corticotropin-releasing factor (Nemeroff, 1992, 1998; Mitchell, 1998); and, most recently, abnormalities in second messenger systems and neuroimaging (Drevets, 1998; Rush et al., 1998, Steffens & Krishnan, 1998). Much current research focuses on how the biological abnormalities interrelate, how they correlate with behavioral and emotional patterns that seem to distinguish one subcategory of major depression from another, and how they respond to diverse forms of therapy. In the search for biological changes with depression, it must be understood that a biological abnormality reliably associated with depression may not actually be a causal factor. For example, a biologic alteration could be a consequence of sleep deprivation or weight loss. Any biological abnormality found in conjunction with any mental disorder may be a cause, a correlate, or a consequence, as discussed in Chapter 2. What drives research is the determination to find which of the biological abnormalities in depression are true causes, especially ones that might be detectable and treatable before the onset of clinical symptoms.
Monoamine Hypothesis For many years the prevailing hypothesis was that depression was caused by an absolute or relative deficiency of monoamine8 transmitters in the brain. This line of research was bolstered by the discovery many years ago that reserpine, a medication for hypertension, inadvertently caused depression. It did so by depleting the brain of both serotonin and the three principal catecholamines (dopamine, norepinephrine, and epinephrine). Such findings led to the “catecholamine hypothesis” and the “indoleamine (i.e., serotonin) hypothesis,” which in due course led to an integrated “monoamine hypothesis” (Thase & Howland, 1995). After more than 30 years of research, however, the monoamine hypothesis has been found insufficient to explain the complex etiology of depression. One problem is that many other neurotransmitter systems are altered in depression, including GABA and acetylcholine (Rush et al., 1998). Another problem is that improvement of monoamine neurotransmission with medications and lifting of the clinical signs of depression do not prove that depression actually is caused by defective monoamine neurotransmission. For example, diuretic medications do not specifically correct the physiological defect underlying congestive heart failure, but they do treat its symptoms. Neither impairment of monoamine synthesis, nor excessive degradation of monoamines, is consistently present in association with depression; monoamine precursors do not have consistent antidepressant effects, and a definite temporal lag exists between the quick elevation in monoamine levels and the symptom relief that does not emerge until weeks later (Duman et al., 1997). To account for these discrepancies, one new model of depression proposes that depression results from reductions in neurotrophic factors that are necessary for the survival and function of particular neurons, especially those found in the hippocampus (Duman et al., 1997). Despite the problems with the hypothesis that monoamine depletion is the primary cause of depression, monoamine impairment is certainly one of the manifestations, or correlates, of depression. Therefore, the monoamine hypothesis remains important for treatment purposes. Many currently available pharmacotherapies that relieve depression or cause mania, or both, enhance monoamine activity. One of the foremost classes of drugs for depression, SSRIs, for example, boost the level of serotonin in the brain.
Evolving Views of Depression An important shortcoming of the monoamine hypothesis was its inattention to the psychosocial risk factors that influence the onset and persistence of depressive episodes. The nature and interpretation of, and the response to, stress clearly have important causal roles in depression. The following discussion illustrates ongoing work aimed at understanding the pathophysiology of depression. While incomplete, it offers a coherent integration of the biological, psychological, and social factors that have long been associated clinically with this disorder. Many decades ago, Hans Selye demonstrated the damaging effects of chronic stress on the HPA axis, the gastrointestinal tract, and the immune system of rats: adrenal hypertrophy, gastric ulceration, and involution of the thymus and lymph nodes (Selye, 1956). Since that time, researchers have provided ample evidence that brain function, and perhaps even anatomic structure, can be influenced by stress, interpretation of stress, and learning (Weiss, 1991; Sapolsky, 1996; McEwen, 1998). Much current research has been directed at stress, the HPA axis, and CRH in the genesis of depression. Depression can be the outcome of severe and prolonged stress (Brown et al., 1994; Frank et al., 1994; Ingram et al., 1998). The acute stress response is characterized by heightened arousal-the fight-or-flight response-that entails mobilization of the sympathetic nervous system and the HPA axis (see Etiology of Anxiety <sec2_1.html>). Many aspects of the acute stress response are exaggerated, persistent, or dysregulated in depression (Thase & Howland, 1995). Increased activity in the HPA axis in depression is viewed as the “most venerable finding in all of biological psychiatry” (Nemeroff, 1998). Increased activity of the HPA axis, however, may be secondary to more primary causes, as was the problem with the monoamine hypothesis of depression. For this reason, much attention has been focused on CRH, which is hypersecreted in depression (Nemeroff, 1992, 1998). CRH is the neuropeptide that is released by the hypothalamus to activate the pituitary in the acute stress response. Yet there are many other sources of CRH in the brain. CRH injections into the brain of laboratory animals produce the signs and symptoms found in depressed patients, including decreased appetite and weight loss, decreased sexual behavior and sleep, and other changes (Sullivan et al., 1998). Furthermore, CRH is found in higher concentrations in the cerebrospinal fluid of depressed patients (Nemeroff, 1998). In autopsy studies of depressed patients, CRH gene expression is elevated, and there are greater numbers of hypothalamic neurons that express CRH (Nemeroff, 1998). These findings have ignited research to uncover how CRH expression in the hypothalamus is regulated, especially by other brain centers such as the hippocampus (Mitchell, 1998). The hippocampus exerts control over the HPA axis through feedback inhibition (Jacobson & Sapolsky, 1991). Shedding light on the regulation of CRH is expected to hold dividends for understanding both anxiety and depression.
Anxiety and Depression Anxiety and depression frequently coexist, so much so that patients with combinations of anxiety and depression are the rule rather than the exception (Barbee, 1998). And many of the medications used to treat either one are often used to treat the other. Why are anxiety and depression so interrelated? Clues to answering this question are expected to come from similarities in antecedents, correlates, and consequences of each condition. Certainly, stressful events are frequent, although not universal, antecedents. Overlapping biochemical correlates are found, most notably, an elevation in CRH (Arborelius et al., 1999). Interestingly, one new line of research finds that long-term consequences of anxiety and depression are evident at the same anatomical site-the hippocampus. Human imaging studies of the hippocampus revealed it to have smaller volume in patients with post-traumatic stress disorder (McEwen, 1998) and in patients with recurrent depression (Sheline, 1996). In the latter study, the degree of volume reduction was correlated with the duration of major depression. In both conditions, excess glucocorticoid exposure was thought to be the culprit in inducing the atrophy of hippocampal neurons. But the complete chain of events leading up to and following the hippocampal damage is not yet known.
Psychosocial and Genetic Factors in Depression If stressful events are the proximate causes of most cases of depression, then why is it that not all people become depressed in the face of stressful events? The answer appears to be that social, psychological, and genetic factors act together to predispose to, or protect against, depression. This section first discusses stressful life events, followed by a discussion of the factors that shape our responses to them.
Stressful Life Events Adult life can be rife with stressful events, as noted earlier, and although not all people with depression can point to some precipitating event, many episodes of depression are associated with some sort of acute or chronic adversity (Brown et al., 1994; Frank et al., 1994; Ingram et al., 1998). The death of a loved one is viewed as one of the most powerful life stressors. The grief that ensues is a universal experience. Common symptoms associated with bereavement include crying spells, appetite and weight loss, and insomnia. Grief, in fact, has such emotional impact that the diagnosis of depressive disorder should not be made unless there are definite complications such as incapacity, psychosis, or suicidal thoughts. The compelling impact of past parental neglect, physical and sexual abuse, and other forms of maltreatment on both adult emotional well-being and brain function is now firmly established for depression. Early disruption of attachment bonds can lead to enduring problems in developing and maintaining interpersonal relationships and problems with depression and anxiety. Research in animals bears this out as well. In both rodents and primates, maternal deprivation stresses young animals, and a pattern of repeated, severe, early trauma from maternal deprivation may predispose an animal to a lifetime of overreactivity to stress (Plotsky et al., 1995). Conversely, early experience with mild, nontraumatic stressors (such as gentle handling) may help to protect or “immunize” animals against more pathologic responses to subsequent severe stress.
Cognitive Factors According to cognitive theories of depression, how individuals view and interpret stressful events contributes to whether or not they become depressed. One prominent theory of depression stems from studies of learned helplessness in animals. The theory posits that depression arises from a cognitive state of helplessness and entrapment (Seligman, 1991). The theory was predicated on experiments in which animals were trained in an enclosure in which shocks were unavoidable and inescapable, regardless of avoidance measures that animals attempted. When they later were placed in enclosures in which evasive action could have succeeded, the animals were inactive, immobile, and unable to learn avoidance maneuvers. The earlier experience engendered a behavioral state of helplessness, one in which actions were seen as ineffectual. In humans there is now ample evidence that the impact of a stressor is moderated by the personal meaning of the event or situation. In other words, the critical factor is the person’s interpretation of the stressor’s potential impact. Thus, an event interpreted as a threat or danger elicits a nonspecific stress response, and an event interpreted as a loss (of either an attachment bond or a sense of competence) elicits more grief-like depressive responses. Heightened vulnerability to depression is linked to a constellation of cognitive patterns that predispose to distorted interpretations of a stressful event (Ingram et al., 1998). For example, a romantic breakup will trigger a much stronger emotional response if the affected person believes, “I am incomplete and empty without her love,” or “I will never find another who makes me feel the way he does.” The cognitive patterns associated with distorted interpretation of stress include relatively harsh or rigid beliefs or attitudes about the importance of romantic love or achievement (again, the centrality of love and work) as well as the tendency to attribute three specific qualities to adverse events: (1) global impact-“This event will have a big effect on me”; (2) internality-“I should have done something to prevent this,” or “This is my fault”; and (3) irreversibility-“I’ll never be able to recover from this.” According to a recent model of cognitive vulnerability to depression, negative cognitions by themselves are not sufficient to engender depression. This model postulates, on the basis of previously gathered empirical evidence, that interactions between negative cognitions and mildly depressed mood are important in the etiology and recurrences of depression. Patterns or styles of thinking stem from prior negative experiences. When they are activated by adverse life events and a mildly depressed mood, a downward spiral ensues, leading to depression (Ingram et al., 1998).
Temperament and Personality Responses to life events also can be linked to personality (Hirschfeld & Shea, 1992). Personality may be understood in terms of one’s attitudes and beliefs as well as more enduring neurobehavioral predispositions referred to as temperaments. The study of personality and temperament is gaining momentum. Neuroticism (a temperament discussed earlier in this chapter) predisposes to anxiety and depression (Clark et al., 1994). Having an easy-going temperament, on the other hand, protects against depression (IOM, 1994). Further, those with severe personality disorder are particularly likely to have a history of early adversity or maltreatment (Browne & Finkelhor, 1986). Temperaments are not destiny, however. Parental influences and individual life experiences may determine whether a shy child remains vulnerable or becomes a healthy, albeit somewhat reserved, adult. In adults, several constellations of personality traits are associated with mood disorders: avoidance, dependence, and traits such as reactivity and impulsivity (Hirschfeld & Shea, 1992). People who have such personality traits not only cope less effectively with stressors but also tend to provoke or elicit adversity. A personality disorder or temperamental disturbance may mediate the relationship between stress and depression.
Gender Major depressive disorder and dysthymia are more prevalent among women than men, as noted earlier. This difference appears in different cultures throughout the world (Weissman et al., 1993). Understanding the gender-related difference is complex and likely related to the interaction of biological and psychosocial factors (Blumenthal, 1994a), including differences in stressful life events as well as to personality (Nolen-Hoeksema et al., in press). Keys to understanding the sex-related difference in rates in the United States may be found in two types of epidemiologic findings: (1) there are no sex-related differences in rates of bipolar disorder (type I) (NIMH, 1998) and, (2) within the agrarian culture of the Old Order Amish of Lancaster, Pennsylvania, the rate of major depressive disorder is both low (i.e., comparable to that of bipolar disorder)9 and equivalent for men and women (Egeland et al., 1983). Something about the environment thus appears to interact with a woman’s biology to cause a disproportionate incidence of depressive episodes among women (Blumenthal, 1994a). Research conducted in working-class neighborhoods suggests that the combination of life stress and inadequate social support contributes to women’s greater susceptibility to depressive symptoms (Brown et al., 1994). Because women tend to use more ruminative ways of coping (e.g., thinking and talking about a problem, rather than seeking out a distracting activity) and, on average, have less economic power, they may be more likely to perceive their problems as less solvable. That perception increases the likelihood of feeling helpless or entrapped by one’s problem. Subtle sex-related differences in hemispheric processing of emotional material may further predispose women to experience emotional stressors more intensely (Baxter et al., 1987). Women are also more likely than men to have experienced past sexual abuse; as noted earlier in this chapter, physical and sexual abuse is strongly associated with the subsequent development of major depressive disorder. Women’s greater vulnerability to depression may be amplified by endocrine and reproductive cycling, as well as by a greater susceptibility to hypothyroidism (Thase & Howland, 1995). Menopause, on the other hand, has little bearing on gender differences in depression. Contrary to popular beliefs, menopause does not appear to be associated with increased rates of depression in women (Pearlstein et al., 1997). Untreated mental health problems are likely to worsen at menopause, but menopause by itself is not a risk factor for depression (Pearce et al., 1995; Thacker, 1997). The increased risk for depression prenatally or after childbirth suggests a role for hormonal influences, although evidence also exists for the role of stressful life events. In short, psychosocial and environmental factors likely interact with biological factors to account for greater susceptibility to depression among women. Poor young women (white, black, and Hispanic) appear to be at the greatest risk for depression compared with all other population groups (Miranda & Green, 1999). They have disproportionately higher rates of past exposure to trauma, including rape, sexual abuse, crime victimization, and physical abuse; poorer support systems; and greater barriers to treatment, including financial hardship and lack of insurance (Miranda & Green, 1999). Many of the same problems apply to single mothers, whose risk of depression is double that of married mothers (Brown & Moran, 1997). The interaction between stressful life events, individual experiences, and genetic factors also plays a role in the etiology of depression in women. Some research suggests that genetic factors, which are discussed below, may alter women’s sensitivity to the depression-inducing effect of stressful life events (Kendler et al., 1995). A recent report of depression in a sample of 2,662 twins found genetic factors in depression to be stronger for women than men, for whom depression was only weakly familial. For both genders, individual environmental experiences played a large role in depression (Bierut et al., 1999).
Genetic Factors in Depression and Bipolar Disorder Depression, and especially bipolar disorder, clearly tend to “run in families,” and a definite association has been scientifically established (Tsuang & Faraone, 1990). Numerous investigators have documented that susceptibility to a depressive disorder is twofold to fourfold greater among the first-degree relatives of patients with mood disorder than among other people (Tsuang & Faraone, 1990). The risk among first-degree relatives of people with bipolar disorder is about six to eight times greater. Some evidence indicates that first-degree relatives of people with mood disorders are also more susceptible than other people to anxiety and substance abuse disorders (Tsuang & Faraone, 1990). Remarkable as those statistics may be, they do not by themselves prove a genetic connection. Inasmuch as first-degree relatives typically live in the same environment, share similar values and beliefs, and are subject to similar stressors, the vulnerability to depression could be due to nurture rather than nature. One method to distinguish environmental from genetic factors is to compare concordance rates among same-sex twins. At least in terms of simple genetic theory, a solely hereditary trait that appears in one member of a set of identical (monozygotic) twins also should always appear in the other twin, whereas the trait should appear only 50 percent of the time in same-sex fraternal (dizygotic) twins. The results of studies comparing the prevalence of depression among twins vary, depending on the specific mood disorder, the age of the study population, and the way the depression is defined. In all instances, however, the reported concordance for mood disorders is greater among monozygotic than among dizygotic twins, and often the proportion is 2 to 1 (Tsuang & Faraone, 1990). In Denmark, Bertelsen and colleagues (1977) found that among 69 monozygotic twins with bipolar illness, 46 co-twins also had bipolar disorder and 14 other co-twins had psychoses, affective personality disorders, or had died by suicide. In studies of monozygotic twins reared separately (“adopted away”), the results also revealed an increased risk of depression and bipolar disorder compared with controls (Mendlewicz & Rainer 1977; Wender et al., 1986). Within the major depressive disorder grouping, greater heritable risk has been associated with more severe, recurrent, or psychotic forms of mood disorders (Tsuang & Faraone, 1990). Those at greater heritable risk also appear more vulnerable to stressful life events (Kendler et al., 1995). The availability of modern molecular genetic methods now allows the translation of clinical associations into identification of specific genes (McInnis, 1993; Baron, 1997). Evidence collected to date strongly suggests that vulnerability to mood disorders may be associated with several genes distributed among various chromosomes. For bipolar disorder, numerous distinct chromosomal regions (called loci) show promise, yet the complex nature of inheritance and methodological problems have encumbered investigators (Baron, 1997). Heritability in some cases may be sex linked or vary depending on whether the affected parent is the father or mother of the individual being studied. The genetic process of anticipation (which has been associated with an expansion of trinucleotide repeats) may further alter the expression of illness across generations (McInnis, 1993). Thus, the genetic complexities of the common depressive disorders ultimately may rival their clinical heterogeneity (Tsuang & Faraone, 1990). Based on a comprehensive review of the genetics literature, the National Institute of Mental Health Genetics Workgroup recently evaluated several mood disorders according to their readiness for large-scale genetics research initiatives. Bipolar disorder was rated in the highest category, meaning that the evidence was strong enough to justify large-scale molecular genetic studies. Depression, eating disorders, obsessive-compulsive disorder, and panic disorder were rated in the second highest category, which called for nonmolecular genetic and/or epidemiological studies to document further their estimated heritability (NIMH, 1998).
Treatment of Mood Disorders So much is known about the assortment of pharmacological and psychosocial treatments for mood disorders that the most salient problem is not with treatment, but rather with getting people into treatment. Surveys consistently document that a majority of individuals with depression receive no specific form of treatment (Katon et al., 1992; Narrow et al., 1993; Wells et al., 1994; Thase, 1996). Nearly 40 percent of people with bipolar disorder are untreated in 1 year, according to the Epidemiologic Catchment Area survey (Regier et al., 1993). Undertreatment of mood disorders stems from many factors, including societal stigma, financial barriers to treatment, underrecognition by health care providers, and underappreciation by consumers of the potential benefits of treatment (e.g., Regier et al., 1988; Wells et al., 1994; Hirschfeld et al., 1997). The symptoms of depression, such as feelings of worthlessness, excessive guilt, and lack of motivation, also deter consumers from seeking treatment; and members of racial and ethnic minority groups often encounter special barriers, as discussed in Chapter 2. Mood disorders have profoundly deleterious consequences on well-being: their toll on quality of life and economic productivity matches that of heart disease and is greater than that of peptic ulcer, arthritis, hypertension, or diabetes (Wells et al., 1989).
Stages of Therapy The treatment of mood disorders is complex because it involves several stages: acute, continuation, and maintenance stages. The stages apply to pharmacotherapy and psychosocial therapy alike. Most patients pass through these stages to restore full functioning. Acute Phase Therapy Acute phase treatment with either psychotherapy or pharmacotherapy covers the time period leading up to an initial treatment response. A treatment response is defined by a significant reduction (i.e., > 50 percent) in symptom severity, such that the patient no longer meets syndromal criteria for the disorder (Frank et al., 1991b). The acute phase for medication typically requires 6 to 8 weeks (Depression Guideline Panel, 1993), during which patients are seen weekly or biweekly for monitoring of symptoms, side effects, dosage adjustments, and support (Fawcett et al., 1987). Psychotherapies during the acute phase for depression typically consist of 6 to 20 weekly visits. Outpatient Treatment. In outpatient clinical trials, about 50 to 70 percent of depressed patients who complete treatment respond to either antidepressants or psychotherapies (Depression Guideline Panel, 1993). An acute treatment response includes the effects of placebo expectancy, spontaneous remission, and active treatment. The magnitude of the active treatment effect may be estimated from randomized clinical trials by subtracting the placebo response rate from that of active medication. Overall, the active treatment effect for major depression typically ranges from 20 to 40 percent, after accounting for a placebo response rate of about 30 percent (Depression Guideline Panel, 1993). Although psychotherapy trials do not employ placebos in the form of an inert pill, they do rely on comparisons of active treatment with psychological placebos (e.g., a form of therapy inappropriate for a given disorder), a comparison form of treatment, or wait list (i.e., no therapy). The figures cited above must be understood as rough averages. The efficacy of specific pharmacotherapies and psychotherapies is covered later in this section. Acute phase therapy is often compromised by patients leaving treatment. Attrition rates from clinical trials often are as high as 30 to 40 percent, and rates of nonadherence10 are even higher (Depression Guideline Panel, 1993). Medication side effects are a factor, as are other factors such as inadequate psychoeducation (resulting in unrealistic expectations about treatment), ambivalence about seeing a therapist or taking medication, and practical roadblocks (e.g., the cost or accessibility of services). Another problem is clinician failure to monitor symptomatic response and to change treatments in a timely manner. Antidepressants should be changed if there is no clear effect within 4 to 6 weeks (Nierenberg et al., 1995; Quitkin et al., 1996). Similar data are not available for psychotherapies, but revisions to the treatment plan should be considered, including the addition of antidepressant medication, if there is no symptomatic improvement within 3 or 4 months (Depression Guideline Panel, 1993). Acute Inpatient Treatment. Hospitalization for acute treatment of depression is necessary for about 5 to 10 percent of major depressive episodes and for up to 50 percent of manic episodes. The principal reasons for hospitalization are overwhelming severity of symptoms and functional incapacity and suicidal or other life-threatening behavior. Hospital median lengths of stay now are about 5 to 7 days for depression and 9 to 14 days for mania. Such abbreviated stays have reduced costs but necessitate greater transitional or aftercare services. Few severely depressed or manic people are in remission after only 1 to 2 weeks of treatment. Electroconvulsive Therapy. As described above, first-line treatment for most people with depression today consists of antidepressant medication, psychotherapy, or the combination (Potter et al., 1991; Depression Guideline Panel, 1993). In situations where these options are not effective or too slow (for example, in a person with delusional depression and intense, unremitting suicidality) electroconvulsive therapy (ECT) may be considered. ECT, sometimes referred to as electroshock or shock treatment, was developed in the 1930s based on the mistaken belief that epilepsy (seizure disorder) and schizophrenia could not exist at the same time in an individual. Accumulated clinical experience-later confirmed in controlled clinical trials, which included the use of simulated or “sham” ECT as a control (Janicak et al., 1985)-determined ECT to be highly effective against severe depression, some acute psychotic states, and mania (Small et al., 1988). No controlled study has shown any other treatment to have superior efficacy to ECT in the treatment of depression (Janicak et al., 1985; Rudorfer et al., 1997). ECT has not been demonstrated to be effective in dysthymia, substance abuse, or anxiety or personality disorders. The foregoing conclusions, and many of those discussed below, are the products of review of extensive research conducted over several decades (Depression Guideline Panel, 1993; Rudorfer et al., 1997) as well as by an independent panel of scientists, practitioners, and consumers (NIH & NIMH Consensus Conference, 1985). ECT consists of a series of brief generalized seizures induced by passing an electric current through the brain by means of two electrodes placed on the scalp. A typical course of ECT entails 6 to 12 treatments, administered at a rate of three times per week, on either an inpatient or outpatient basis. The exact mechanisms by which ECT exerts its therapeutic effect are not yet known. The production of an adequate, generalized seizure using the proper amount of electrical stimulation at each treatment session is required for therapeutic efficacy (Sackheim et al., 1993). With the development of effective medications for the treatment of major mental disorders a half-century ago, the need for ECT lessened but did not disappear. Prior to that time, ECT often had been administered for a variety of conditions for which it is not effective, and administered without anesthesia or neuromuscular blockade. The result was grand mal seizures that could produce injuries and even fractures. Despite the availability of a range of effective antidepressant medications and psychotherapies, as discussed above, ECT continues to be used (Rosenbach et al., 1997), occupying a narrower but important niche. It is generally reserved for the special circumstances where the usual first-line treatments are ineffective or cannot be taken, or where ECT is known to be particularly beneficial, such as depression or mania accompanied by psychosis or catatonia (NIH & NIMH Consensus Conference, 1985; Depression Guideline Panel, 1993; Potter & Rudorfer, 1993). Examples of specific indications include depression unresponsive to multiple medication trials, or accompanied by a physical illness or pregnancy, which renders the use of a usually preferred antidepressant dangerous to the patient or to a developing fetus. Under such circumstances, carefully weighing risks and benefits, ECT may be the safest treatment option for severe depression. It should be administered under controlled conditions, with appropriate personnel (Rudorfer et al., 1997). Although the average 60 to 70 percent response rate seen with ECT is comparable to that obtained with pharmacotherapy, there is evidence that the antidepressant effect of ECT occurs faster than that seen with medication, encouraging the use of ECT where depression is accompanied by potentially uncontrollable suicidal ideas and actions (Rudorfer et al., 1997). However, ECT does not exert a long-term protection against suicide. Indeed, it is now recognized that a single course of ECT should be regarded as a short-term treatment for an acute episode of illness. To sustain the response to ECT, continuation treatment, often in the form of antidepressant and/or mood stabilizer medication, must be instituted (Sackeim, 1994). Individuals who repeatedly relapse following ECT despite continuation medication may be candidates for maintenance ECT, delivered on an outpatient basis at a rate of one treatment weekly to as infrequently as monthly (Sackeim, 1994; Rudorfer et al., 1997). The major risks of ECT are those of brief general anesthesia, which was introduced along with muscle relaxation and oxygenation to protect against injury and to reduce patient anxiety. There are virtually no absolute health contraindications precluding its use where warranted (Potter & Rudorfer, 1993; Rudorfer et al., 1997). The most common adverse effects of this treatment are confusion and memory loss for events surrounding the period of ECT treatment. The confusion and disorientation seen upon awakening after ECT typically clear within an hour. More persistent memory problems are variable. Most typical with standard, bilateral electrode placement (one electrode on each side of the head) has been a pattern of loss of memories for the time of the ECT series and extending back an average of 6 months, combined with impairment with learning new information, which continues for perhaps 2 months following ECT (NIH & NIMH Consensus Conference, 1985). Well-designed neuropsychological studies have consistently shown that by several months after completion of ECT, the ability to learn and remember are normal (Calev, 1994). Although most patients return to full functioning following successful ECT, the degree of post-treatment memory impairment and resulting impact on functioning are highly variable across individuals (NIH & NIMH Consensus Conference, 1985; CMHS, 1998). While clearly the exception rather than the rule, no reliable data on the incidence of severe post-ECT memory impairment are available. Fears that ECT causes gross structural brain pathology have not been supported by decades of methodologically sound research in both humans and animals (NIH & NIMH Consensus Conference, 1985; Devanand et al., 1994; Weiner & Krystal, 1994; Greenberg, 1997; CMHS, 1998). The decision to use ECT must be evaluated for each individual, weighing the potential benefits and known risks of all available and appropriate treatments in the context of informed consent (NIH & NIMH Consensus Conference, 1985). Advances in treatment technique over the past generation have enabled a reduction of adverse cognitive effects of ECT (NIH & NIMH Consensus Conference, 1985; Rudorfer et al., 1997). Nearly all ECT devices deliver a lower current, brief-pulse electrical stimulation, rather than the original sine wave output; with a brief pulse electrical wave, a therapeutic seizure may be induced with as little as one-third the electrical power as with the older method, thereby reducing the potential for confusion and memory disturbance (Andrade et al., 1998). Placement of both stimulus electrodes on one side of the head (“unilateral” ECT), over the nondominant (generally right) cerebral hemisphere, results in delivery of the initial electrical stimulation away from the primary learning and memory centers. According to several controlled trials, unilateral ECT is associated with virtually no detectable, persistent memory loss (Horne et al., 1985; NIH Consensus Conference, 1985; Rudorfer et al., 1997). However, most clinicians find unilateral ECT less potent and more slowly acting an intervention than conventional bilateral ECT, particularly in the most severe cases of depression or in mania. One approach that is sometimes used is to begin a trial of ECT with unilateral electrode placement and switch to bilateral treatment after about six treatments if there has been no response. Research has demonstrated that the relationship of electrical dose to clinical response differs depending on electrode placement; for bilateral ECT, as long as an adequate seizure is obtained, any additional dosage will merely add to the cognitive toxicity, whereas for unilateral electrode placement, a therapeutic effect will not be achieved unless the electrical stimulus is more than minimally above the seizure threshold (Sackeim et al., 1993). Even a moderately high electrical dosage in unilateral ECT still has fewer cognitive adverse effects than bilateral ECT. On the other hand, high-dose bilateral ECT may be unnecessarily risky and may be a preventable cause of severe memory impairment. Some types of medication, such as lithium, also add to confusion and cognitive impairment when given during a course of ECT and are best avoided. Medications that raise the seizure threshold and make it harder to obtain a therapeutic effect from ECT, including anticonvulsants and some minor tranquilizers, may also need to be tapered or discontinued. Informed consent is an integral part of the ECT process (NIH & NIMH Consensus Conference, 1985). The potential benefits and risks of this treatment, and of available alternative interventions, should be carefully reviewed and discussed with patients and, where appropriate, family or friends. Prospective candidates for ECT should be informed, for example, that its benefits are short-lived without active continuation treatment, and that there may be some risk of permanent severe memory loss after ECT. In most cases of depression, the benefit-to-risk ratio will favor the use of medication and/or psychotherapy as the preferred course of action (Depression Guideline Panel, 1993). Where medication has not succeeded, or is fraught with unusual risk, or where the potential benefits of ECT are great, such as in delusional depression, the balance of potential benefits to risks may tilt in favor of ECT. Active discussion with the treatment team, supplemented by the growing amount of printed and videotaped information packages for consumers, is necessary in the decisionmaking process, both prior to and throughout a course of ECT. Consent may be revoked at any time during a series of ECT sessions. Although many people have fears related to stories of forced ECT in the past, the use of this modality on an involuntary basis today is uncommon. Involuntary ECT may not be initiated by a physician or family member without a judicial proceeding. In every state, the administration of ECT on an involuntary basis requires such a judicial proceeding at which patients may be represented by legal counsel. As a rule, such petitions are granted only where the prompt institution of ECT is regarded as potentially lifesaving, as in the case of a person who is in grave danger because of lack of food or fluid intake caused by catatonia. Recent epidemiological surveys show that the modern use of ECT is generally limited to evidence-based indications (Hermann et al., 1999). Indeed, concern has been raised that in some settings, particularly in the public sector and outside major metropolitan areas, ECT may be underutilized due to the wide variability in the availability of this treatment across the country (Hermann et al., 1995). Consequently, minority patients tend to be underrepresented among those receiving ECT (Rudorfer et al., 1997). On balance, the evidence supports the conclusion that modern ECT is among those treatments effective for the treatment of select severe mental disorders, when used in accord with current standards of care, including appropriate informed consent. Continuation Phase Therapy Successful acute phase antidepressant pharmacotherapy or ECT should almost always be followed by at least 6 months of continued treatment (Prien & Kupfer, 1986; Depression Guideline Panel, 1993; Rudorfer et al., 1997). During this phase, known as the continuation phase, most patients are seen biweekly or monthly. The primary goal of continuation pharmacotherapy is to prevent relapse (i.e., an exacerbation of symptoms sufficient to meet syndromal criteria). Continuation pharmacotherapy reduces the risk of relapse from 40-60 percent to 10-20 percent (Prien & Kupfer, 1986; Thase, 1993). Relapse despite continuation pharmacotherapy might suggest either nonadherence (Myers & Branthwaithe, 1992) or loss of a placebo response (Quitkin et al., 1993a). A second goal of continuation pharmacotherapy is consolidation of a response into a complete remission and subsequent recovery (i.e., 6 months of sustained remission). A remission is defined as a complete resolution of affective symptoms to a level similar to healthy people (Frank et al., 1991a). As residual symptoms are associated with increased relapse risk (Keller et al., 1992; Thase et al., 1992), recovery should be achieved before withdrawing antidepressant pharmacotherapy. Many psychotherapists similarly taper a successful course of treatment by scheduling several sessions (every other week or monthly) prior to termination. There is some evidence, albeit weak, that relapse is less common following successful treatment with one type of psychotherapy-cognitive-behavioral therapy-than with antidepressants (Kovacs et al., 1981; Blackburn et al., 1986; Simons et al., 1986; Evans et al., 1992). If confirmed, this advantage may offset the greater short-term costs of psychotherapy. Maintenance Phase Therapies Maintenance pharmacotherapy is intended to prevent future recurrences of mood disorders (Kupfer, 1991; Thase, 1993; Prien & Kocsis, 1995). A recurrence is viewed as a new episode of illness, in contrast to relapse, which represents reactivation of the index episode (Frank et al., 1991a). Maintenance pharmacotherapy is typically recommended for individuals with a history of three or more depressive episodes, chronic depression, or bipolar disorder (Kupfer, 1991; Thase, 1993; Prien & Kocsis, 1995). Maintenance pharmacotherapy, which may extend for years, typically requires monthly or quarterly visits. Longer term, preventive psychotherapy to prevent recurrences has not been studied extensively. However, in one study of patients with highly recurrent depression, monthly sessions of interpersonal psychotherapy were significantly more effective than placebo but less effective than pharmacotherapy (Frank et al., 1991a). 8 Monoamine neurotransmitters are a chemical class that includes catecholamines (norepinephrine, epinephrine, dopamine) and indoleamines (serotonin). 9 A small, albeit noteworthy, sex-related difference is seen in the higher incidence of rapid-cycling bipolar disorder in women (cited in Blumenthal, 1994). 10 Nonadherence is defined as lack of adherence to prescribed activities such as keeping appointments, taking medication, and completing assignments
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