Vital-affective symptom connectivity during electroconvulsive therapy distinguishes depression remission outcomes: A cross-lagged panel network study

Melissa G Zandstra; Gabriela Lunansky; Floortje E Scheepers; Tessa F Blanken; Tom K Birkenhager; Dieneke Bloemkolk; Birit F P Broekman; Philip van Eijndhoven; Eric van Exel; Frank L Gerritse; Johanna M Hegeman; Willemijn Heijnen; Rob M Kok; Dore Loef; Roel J T Mocking; Jasper O Nuninga; Mardien L Oudega; Didi Rhebergen; Henricus G Ruhe; Bart P F Rutten; Bart Schut; Iris E Sommer; Indira Tendolkar; Rosanne J Turner; Esmée Verwijk; Hanneke van Welie; Noor Woerdman; Annemiek Dols; Edwin van Dellen; Metten Somers

doi:10.1016/j.brs.2026.103058

Vital-affective symptom connectivity during electroconvulsive therapy distinguishes depression remission outcomes: A cross-lagged panel network study

Melissa G Zandstra^*
, Gabriela Lunansky
, Floortje E Scheepers
, Tessa F Blanken
, Tom K Birkenhager
, Dieneke Bloemkolk
, Birit F P Broekman
, Philip van Eijndhoven
, Eric van Exel
, Frank L Gerritse
, Johanna M Hegeman
, Willemijn Heijnen
, Rob M Kok
, Dore Loef
, Roel J T Mocking
, Jasper O Nuninga
, Mardien L Oudega
, Didi Rhebergen
, Henricus G Ruhe
, Bart P F Rutten

Bart Schut, Iris E Sommer, Indira Tendolkar, Rosanne J Turner, Esmée Verwijk, Hanneke van Welie, Noor Woerdman, Annemiek Dols, Edwin van Dellen, Metten Somers

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

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Abstract

Background: Electroconvulsive therapy (ECT) is effective for depression, but symptom dynamics during treatment remain unclear. Network approaches may clarify symptom relations and identify patterns linked to remission. Objective: Examining symptom dynamics during ECT using temporal network modeling and comparing baseline and temporal symptom networks between remitters and non-remitters. Methods: Using the Dutch ECT Consortium (N = 857, unipolar/bipolar depression), we examined seven harmonized symptoms from the 17-item Hamilton Depression Rating Scale (HDRS-17) and Montgomery–Åsberg Depression Rating Scale (MADRS) over the first five weeks of treatment. We estimated baseline networks using partial correlations and temporal networks using Cross-Lagged Panel Network analysis, which quantified each symptom's in-prediction and out-prediction. Between remitters (N = 413) and non-remitters (N = 379), baseline networks were compared using the Network Comparison Test, while temporal networks were compared via network density, Jaccard overlap, and edge correlations. Results: In the full sample (65.2% female, mean age 61.3 ± 15.5 years), suicidal thoughts exerted the strongest influence on other symptoms (i.e., highest out-prediction). Baseline networks did not differ by outcome, but temporal networks did: remitters showed greater density than non-remitters (χ² = 8.20, p < 0.01), with low overlap in edges (Jaccard = 0.25), and non-significant edge-weight correlations (r = 0.16; p = 0.46) between groups. Remitters displayed integrated affective-vital symptom connections, while non-remitters showed fragmented subnetworks. Conclusions: Reductions in suicidal thoughts preceded broader symptom improvements, suggesting this symptom warrants monitoring. Remitters showed coordinated symptom reduction where affective and vital symptoms reinforced each other, while non-remitters showed independent reduction. These findings provide insights into symptom dynamics during ECT.

Original language	English
Article number	103058
Journal	Brain stimulation
Volume	19
Issue number	2
Early online date	17 Feb 2026
DOIs	https://doi.org/10.1016/j.brs.2026.103058
Publication status	Published - Mar 2026

Keywords

Bipolar disorder
Electroconvulsive therapy
Major depressive disorder
Network analysis
Symptom dynamics
Temporal symptom networks
Treatment outcome

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Zandstra, M. G., Lunansky, G., Scheepers, F. E., Blanken, T. F., Birkenhager, T. K., Bloemkolk, D., Broekman, B. F. P., van Eijndhoven, P., van Exel, E., Gerritse, F. L., Hegeman, J. M., Heijnen, W., Kok, R. M., Loef, D., Mocking, R. J. T., Nuninga, J. O., Oudega, M. L., Rhebergen, D., Ruhe, H. G., ... Somers, M. (2026). Vital-affective symptom connectivity during electroconvulsive therapy distinguishes depression remission outcomes: A cross-lagged panel network study. Brain stimulation, 19(2), Article 103058. https://doi.org/10.1016/j.brs.2026.103058

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title = "Vital-affective symptom connectivity during electroconvulsive therapy distinguishes depression remission outcomes: A cross-lagged panel network study",

abstract = "Background: Electroconvulsive therapy (ECT) is effective for depression, but symptom dynamics during treatment remain unclear. Network approaches may clarify symptom relations and identify patterns linked to remission. Objective: Examining symptom dynamics during ECT using temporal network modeling and comparing baseline and temporal symptom networks between remitters and non-remitters. Methods: Using the Dutch ECT Consortium (N = 857, unipolar/bipolar depression), we examined seven harmonized symptoms from the 17-item Hamilton Depression Rating Scale (HDRS-17) and Montgomery–{\AA}sberg Depression Rating Scale (MADRS) over the first five weeks of treatment. We estimated baseline networks using partial correlations and temporal networks using Cross-Lagged Panel Network analysis, which quantified each symptom's in-prediction and out-prediction. Between remitters (N = 413) and non-remitters (N = 379), baseline networks were compared using the Network Comparison Test, while temporal networks were compared via network density, Jaccard overlap, and edge correlations. Results: In the full sample (65.2\% female, mean age 61.3 ± 15.5 years), suicidal thoughts exerted the strongest influence on other symptoms (i.e., highest out-prediction). Baseline networks did not differ by outcome, but temporal networks did: remitters showed greater density than non-remitters (χ2 = 8.20, p < 0.01), with low overlap in edges (Jaccard = 0.25), and non-significant edge-weight correlations (r = 0.16; p = 0.46) between groups. Remitters displayed integrated affective-vital symptom connections, while non-remitters showed fragmented subnetworks. Conclusions: Reductions in suicidal thoughts preceded broader symptom improvements, suggesting this symptom warrants monitoring. Remitters showed coordinated symptom reduction where affective and vital symptoms reinforced each other, while non-remitters showed independent reduction. These findings provide insights into symptom dynamics during ECT.",

keywords = "Bipolar disorder, Electroconvulsive therapy, Major depressive disorder, Network analysis, Symptom dynamics, Temporal symptom networks, Treatment outcome",

author = "Zandstra, \{Melissa G\} and Gabriela Lunansky and Scheepers, \{Floortje E\} and Blanken, \{Tessa F\} and Birkenhager, \{Tom K\} and Dieneke Bloemkolk and Broekman, \{Birit F P\} and \{van Eijndhoven\}, Philip and \{van Exel\}, Eric and Gerritse, \{Frank L\} and Hegeman, \{Johanna M\} and Willemijn Heijnen and Kok, \{Rob M\} and Dore Loef and Mocking, \{Roel J T\} and Nuninga, \{Jasper O\} and Oudega, \{Mardien L\} and Didi Rhebergen and Ruhe, \{Henricus G\} and Rutten, \{Bart P F\} and Bart Schut and Sommer, \{Iris E\} and Indira Tendolkar and Turner, \{Rosanne J\} and Esm{\'e}e Verwijk and \{van Welie\}, Hanneke and Noor Woerdman and Annemiek Dols and \{van Dellen\}, Edwin and Metten Somers",

note = "Publisher Copyright: {\textcopyright} 2026",

year = "2026",

month = mar,

doi = "10.1016/j.brs.2026.103058",

language = "English",

volume = "19",

journal = "Brain stimulation",

issn = "1935-861X",

publisher = "Elsevier",

number = "2",

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Zandstra, MG, Lunansky, G, Scheepers, FE, Blanken, TF, Birkenhager, TK, Bloemkolk, D, Broekman, BFP, van Eijndhoven, P, van Exel, E, Gerritse, FL, Hegeman, JM, Heijnen, W, Kok, RM, Loef, D, Mocking, RJT, Nuninga, JO, Oudega, ML, Rhebergen, D, Ruhe, HG, Rutten, BPF, Schut, B, Sommer, IE, Tendolkar, I, Turner, RJ, Verwijk, E, van Welie, H, Woerdman, N, Dols, A , van Dellen, E & Somers, M 2026, 'Vital-affective symptom connectivity during electroconvulsive therapy distinguishes depression remission outcomes: A cross-lagged panel network study', Brain stimulation, vol. 19, no. 2, 103058. https://doi.org/10.1016/j.brs.2026.103058

TY - JOUR

T1 - Vital-affective symptom connectivity during electroconvulsive therapy distinguishes depression remission outcomes

T2 - A cross-lagged panel network study

AU - Zandstra, Melissa G

AU - Lunansky, Gabriela

AU - Scheepers, Floortje E

AU - Blanken, Tessa F

AU - Birkenhager, Tom K

AU - Bloemkolk, Dieneke

AU - Broekman, Birit F P

AU - van Eijndhoven, Philip

AU - van Exel, Eric

AU - Gerritse, Frank L

AU - Hegeman, Johanna M

AU - Heijnen, Willemijn

AU - Kok, Rob M

AU - Loef, Dore

AU - Mocking, Roel J T

AU - Nuninga, Jasper O

AU - Oudega, Mardien L

AU - Rhebergen, Didi

AU - Ruhe, Henricus G

AU - Rutten, Bart P F

AU - Schut, Bart

AU - Sommer, Iris E

AU - Tendolkar, Indira

AU - Turner, Rosanne J

AU - Verwijk, Esmée

AU - van Welie, Hanneke

AU - Woerdman, Noor

AU - Dols, Annemiek

AU - van Dellen, Edwin

AU - Somers, Metten

PY - 2026/3

Y1 - 2026/3

N2 - Background: Electroconvulsive therapy (ECT) is effective for depression, but symptom dynamics during treatment remain unclear. Network approaches may clarify symptom relations and identify patterns linked to remission. Objective: Examining symptom dynamics during ECT using temporal network modeling and comparing baseline and temporal symptom networks between remitters and non-remitters. Methods: Using the Dutch ECT Consortium (N = 857, unipolar/bipolar depression), we examined seven harmonized symptoms from the 17-item Hamilton Depression Rating Scale (HDRS-17) and Montgomery–Åsberg Depression Rating Scale (MADRS) over the first five weeks of treatment. We estimated baseline networks using partial correlations and temporal networks using Cross-Lagged Panel Network analysis, which quantified each symptom's in-prediction and out-prediction. Between remitters (N = 413) and non-remitters (N = 379), baseline networks were compared using the Network Comparison Test, while temporal networks were compared via network density, Jaccard overlap, and edge correlations. Results: In the full sample (65.2% female, mean age 61.3 ± 15.5 years), suicidal thoughts exerted the strongest influence on other symptoms (i.e., highest out-prediction). Baseline networks did not differ by outcome, but temporal networks did: remitters showed greater density than non-remitters (χ2 = 8.20, p < 0.01), with low overlap in edges (Jaccard = 0.25), and non-significant edge-weight correlations (r = 0.16; p = 0.46) between groups. Remitters displayed integrated affective-vital symptom connections, while non-remitters showed fragmented subnetworks. Conclusions: Reductions in suicidal thoughts preceded broader symptom improvements, suggesting this symptom warrants monitoring. Remitters showed coordinated symptom reduction where affective and vital symptoms reinforced each other, while non-remitters showed independent reduction. These findings provide insights into symptom dynamics during ECT.

AB - Background: Electroconvulsive therapy (ECT) is effective for depression, but symptom dynamics during treatment remain unclear. Network approaches may clarify symptom relations and identify patterns linked to remission. Objective: Examining symptom dynamics during ECT using temporal network modeling and comparing baseline and temporal symptom networks between remitters and non-remitters. Methods: Using the Dutch ECT Consortium (N = 857, unipolar/bipolar depression), we examined seven harmonized symptoms from the 17-item Hamilton Depression Rating Scale (HDRS-17) and Montgomery–Åsberg Depression Rating Scale (MADRS) over the first five weeks of treatment. We estimated baseline networks using partial correlations and temporal networks using Cross-Lagged Panel Network analysis, which quantified each symptom's in-prediction and out-prediction. Between remitters (N = 413) and non-remitters (N = 379), baseline networks were compared using the Network Comparison Test, while temporal networks were compared via network density, Jaccard overlap, and edge correlations. Results: In the full sample (65.2% female, mean age 61.3 ± 15.5 years), suicidal thoughts exerted the strongest influence on other symptoms (i.e., highest out-prediction). Baseline networks did not differ by outcome, but temporal networks did: remitters showed greater density than non-remitters (χ2 = 8.20, p < 0.01), with low overlap in edges (Jaccard = 0.25), and non-significant edge-weight correlations (r = 0.16; p = 0.46) between groups. Remitters displayed integrated affective-vital symptom connections, while non-remitters showed fragmented subnetworks. Conclusions: Reductions in suicidal thoughts preceded broader symptom improvements, suggesting this symptom warrants monitoring. Remitters showed coordinated symptom reduction where affective and vital symptoms reinforced each other, while non-remitters showed independent reduction. These findings provide insights into symptom dynamics during ECT.

KW - Bipolar disorder

KW - Electroconvulsive therapy

KW - Major depressive disorder

KW - Network analysis

KW - Symptom dynamics

KW - Temporal symptom networks

KW - Treatment outcome

UR - https://www.scopus.com/pages/publications/105030484281

U2 - 10.1016/j.brs.2026.103058

DO - 10.1016/j.brs.2026.103058

M3 - Article

C2 - 41713680

SN - 1935-861X

VL - 19

JO - Brain stimulation

JF - Brain stimulation

IS - 2

M1 - 103058

ER -

Vital-affective symptom connectivity during electroconvulsive therapy distinguishes depression remission outcomes: A cross-lagged panel network study

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