The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders

Şengül Kocamer ŞAHİN; Celal YAŞAMALI; Muhammet Berkay ÖZYÜREK; Gülçin ELBOĞA; Abdurrahman ALTINDAĞ; Enes ELMALI; Handan DEMİRBAŞ

doi:10.28982/josam.637840

Journal of Surgery and Medicine

Research Article

The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders

Year 2019, Volume 3, Issue 11, 793 - 795, 01.11.2019

Şengül Kocamer ŞAHİN Celal YAŞAMALI Muhammet Berkay ÖZYÜREK Gülçin ELBOĞA Abdurrahman ALTINDAĞ Enes ELMALI Handan DEMİRBAŞ

https://doi.org/10.28982/josam.637840

Abstract

Aim: Growing evidence supports the role of inflammation in the etiology of bipolar disorder. Efficacy of electroconvulsive therapy (ECT) in the manic and depressive phases of bipolar disorder is well-known. We aimed to investigate the effect of ECT on the neutrophil/lymphocyte (NLR) and platelet/lymphocyte ratios (PLR), which are newly defined subclinical inflammatory markers in patients with bipolar disorder.

Methods: Patients who received ECT due to the diagnosis of bipolar disorder according to DSM-5 in the last two years and the same number of individuals as the control group were included in this case-control study. NLR and PLR were compared between the patient and control groups, and before and after ECT in the patient group.

Results: A total of 104 individuals were included in the study. Among included patients with bipolar disorder, 39 were in depressive episode and 13 were in manic episode. 52 healthy individuals were identified as control group. Patients' mean age was 36.0 (13.4) years. There were no significant differences between the groups in terms of age, gender, marital status, and smoking. NLR values were significantly higher in the patient group before and after ECT compared to the control group. No difference was found between PLR ratios. There was no significant difference between the NLR, PLR values before and after ECT in the patient group.

Conclusion: This study supports the hypothesis that subclinical inflammation exists in bipolar patients in both manic and depressive phases and it continues after ECT. Large-scale studies are needed to determine the effects of ECT on subclinical inflammation.

Keywords

Neutrophil, Lymphocyte, Monocyte, Electroconvulsive therapy, Bipolar disorder

References

1. Freund N, Juckel G. Bipolar Disorder: Its Etiology and How to Model in Rodents. Psychiatric Disorders. Humana, New York, NY 2019;61-77.
2. Adigüzel V, Özdemir N, Şahin ŞK. Childhood traumas in euthymic patients with bipolar disorder in Eastern Turkey and its relations with suicide risk and aggression. Nordic Journal of Psychiatry. 2019;73(8):490-6.
3. Rosenblat JD, McIntyre RS. Bipolar Disorder and Inflammation. Psychiatr Clin North Am. 2016;39:125-37. doi: 10.1016/j.psc.2015.09.006.
4. Wang TY, Lee SY, Hu MC, Chen SL, Chang YH, Chu CH, et al. More inflammation but less brain-derived neurotrophic factor in antisocial personality disorder. Psychoneuroendocrinology. 2017;85:42-8.
5. Sunbul M, Gerin F, Durmus E, Kivrak T, Sari I, Tigen K, et al. Neutrophil to lymphocyte and platelet to lymphocyte ratio in patients with dipper versus non-dipper hypertension. Clin Exp Hypertens. 2014;36:217-21.
6. Yıldırım ÖT, Akşit E, Aydın F, Aydın AH, Dağtekin E. Can neutrophil to lymphocyte ratio and platelet to lymphocyte ratio be used as biomarkers for non-dipper blood pressure? J Surg Med. 2018;3(1):4-7.
7. Çelen S, Günseren KÖ, Özlülerden Y, Mete A, Tuncay ÖL, Yavaşcaoğlu İ. Does neutrophil-lymphocyte ratio show recurrence in patients who underwent curative resection for non-muscle-invasive bladder cancer? J Surg Med. 2019;3(4):324-7.
8. Krenn-Pilko S, Langsenlehner U, Thurner EM, Stojakovic T, Pichler M, Gerger A, et al. The elevated preoperative platelet-to-lymphocyte ratio predicts poor prognosis in breast cancer patients. Br J Cancer. 2014;13;110:2524-30.
9. Cummings M, Merone L, Keeble C, Burland L, Grzelinski M, Sutton K, et al. Preoperative neutrophil:lymphocyte and platelet:lymphocyte ratios predict endometrial cancer survival. Br J Cancer. 2015;14(113):311-20.
10. Kalelioglu T, Akkus M, Karamustafalioglu N, Genc A, Genc ES, Cansiz A, et al. Neutrophil-lymphocyte and platelet-lymphocyte ratios as inflammation markers for bipolar disorder. Psychiatry Res. 2015;30(228):925-7. doi: 10.1016/j.psychres.2015.05.110.
11. Perugi G, Medda P, Toni C, Mariani MG, Socci C, Mauri M. The Role of Electroconvulsive Therapy (ECT) in Bipolar Disorder: Effectiveness in 522 Patients with Bipolar Depression, Mixed-state, Mania and Catatonic Features. Curr Neuropharmacol. 2017;15:359-371. doi: 10.2174/1570159X14666161017233642.
12. Eroğlu MZ, İçbay E, Tamam L. Bir üniversite hastanesi psikiyatri kliniğinde elektrokonvülzif tedavi uygulanan hastaların demografik ve klinik özellikleri. Dicle Tıp Dergisi. 2012;39(3):371-6.
13. Yrondi A, Sporer M, Péran P, Schmitt L, Arbus C, Sauvaget A. Electroconvulsive therapy, depression, the immune system and inflammation: A systematic review. Brain Stimul. 2018;11:29-51. doi: 10.1016/j.brs.2017.10.013. Epub 2017 Oct 19.
14. Rosenblat JD, McIntyre RS. Are medical comorbid conditions of bipolar disorder due to immune dysfunction? Acta Psychiatr Scand. 2015;132:180-91. doi: 10.1111/acps.12414.
15. Modabbernia A, Taslimi S, Brietzke E, Ashrafi M. Cytokine alterations in bipolar disorder: a meta-analysis of 30 studies. Biol Psychiatry. 2013;1;74:15-25. doi: 10.1016/j.biopsych.2013.01.007.
16. Ortiz-Domínguez A, Hernández ME, Berlanga C, Gutiérrez-Mora D, Moreno J, Heinze G, et al. Immune variations in bipolar disorder: phasic differences. Bipolar Disord. 2007;9:596-602.
17. Brietzke E, Stertz L, Fernandes BS, Kauer-Sant'anna M, Mascarenhas M, Escosteguy Vargas A, et al. Comparison of cytokine levels in depressed, manic and euthymic patients with bipolar disorder. J Affect Disord. 2009;116:214-7.
18. Bond DJ, Andreazza AC, Hughes J, Dhanoa T, Torres IJ, Kozicky JM, et al. Association of peripheral inflammation with body mass index and depressive relapse in bipolar disorder. Psychoneuroendocrinology. 2016;65:76-83. doi: 10.1016/j.psyneuen.2015.12.012.
19. Freire TFV, Rocha NSD, Fleck MPA. The association of electroconvulsive therapy to pharmacological treatment and its influence on cytokines. J Psychiatr Res. 2017 Sep;92:205-11. doi:10.1016/j.jpsychires.2017.05.004.
20. Yrondi A, Sporer M, Péran P, Schmitt L, Arbus C, Sauvaget A. Electroconvulsive therapy, depression, the immune system and inflammation: A systematic review. Brain Stimul. 2018;11:29-51. doi: 10.1016/j.brs.2017.10.013.
21. Bulut M, Altındağ A, Deveci Z, Kaya MC, Bülbül F, Taşkın A, et al. Oxidative parameters in bipolar patients treated with electroconvulsive therapy and pharmacotherapy. Journal of Mood Disorders. 2013;3:93-9.
22. Kargar M, Yoosefi A, Akhondzadeh S, Artonian V, Ashouri A, Ghaeli P. Effect of Adjunctive Celecoxib on BDNF in Manic Patients Undergoing Electroconvulsive Therapy: a Randomized Double Blind Controlled Trial. Pharmacopsychiatry. 2015;48:268-73. doi: 10.1055/s-0035-1559667.
23. Howren MB, Lamkin DM, Suls J. Associations of depression with C-reactive protein, IL-1, and IL-6: a meta-analysis. Psychosom Med. 2009;71(2):171-86. doi: 10.1097/PSY.0b013e3181907c1b.
24. Huang G, Chen H, Wang Q, Hong X, Hu P, Xiao M, et al. High platelet-to-lymphocyte ratio is associated with post-stroke depression. J Affect Disord. 2018;246:105-11. doi: 10.1016/j.jad.2018.12.012.
25. Himmerich H, Bartsch S, Hamer H, Mergl R, Schönherr J, Petersein C, et al. Modulation of cytokine production by drugs with antiepileptic or mood stabilizer properties in anti-CD3-and anti-Cd40-stimulated blood in vitro. Oxid Med Cell Longev. 2014;2014:806162
26. Boufidou F, Nikolaou C, Alevizos B, Liappas IA, Christodoulou GN. Cytokine production in bipolar affective disorder patients under lithium treatment. Journal of Affective Disorders. 2004;82(2):309-13.
27. Mørch RH, Dieset I, Færden A, Hope S, Aas M, Nerhus M, Aukrust P. Inflammatory evidence for the psychosis continuum model. Psychoneuroendocrinology. 2016;67:189-97.

Elektrokonvülsif terapinin bipolar bozukluklarda subklinik inflamasyon üzerine etkisi

Year 2019, Volume 3, Issue 11, 793 - 795, 01.11.2019

Şengül Kocamer ŞAHİN Celal YAŞAMALI Muhammet Berkay ÖZYÜREK Gülçin ELBOĞA Abdurrahman ALTINDAĞ Enes ELMALI Handan DEMİRBAŞ

https://doi.org/10.28982/josam.637840

Abstract

Amaç: Biriken kanıtlar, bipolar bozukluğun etiyopatogenezinde enflamasyonun rolünü desteklemektedir. Elektrokonvülsif terapi (EKT) bipolar bozukluğun manik ve depresif dönemlerinde etkindir. Bu çalışmada bipolar bozukluk hastalarında EKT’nin remisyona ulaşan hastalarda yeni bulunan subklinik inflamatuar belirteçler olan nötrofil/lenfosit (N/L), platelet/lenfosit (P/L) oranlarına etkisini araştırmayı amaçladık.

Yöntemler: Bu olgu-kontrol çalışmasına son iki yılda DSM-5’e göre bipolar bozukluk tanısı ile kliniğe yatırılarak EKT uygulanan manik ve depresif dönem hastaları ile aynı sayıda kontrol grubu alındı. Hasta ve kontrol grubu N/L, P/L oranları açısından karşılaştırıldı. Elli iki hasta EKT öncesi ve sonrası N/L, P/L oranları açısından ayrıca karşılaştırıldı.

Bulgular: Çalışmamıza 39 bipolar bozukluk depresif dönem, 13 bipolar bozukluk manik dönem, 52 sağlıklı kontrol olmak üzere toplam 104 olgu alınmıştır. Yaş, cinsiyet, medeni durum, sigara içme açısından sağlıklı kontroller ve hastalar arasında anlamlı fark bulunmamıştır. EKT öncesi hasta grubunda N/L değerleri kontrol grubuna göre anlamlı oranda yüksek bulunmuştur. EKT sonrası N/L değerleri kontrol grubuna göre anlamlı oranda yüksek bulunmuş, P/L oranları arasında fark bulunmamıştır. Hasta grubunda EKT öncesi ve sonrası N/L, P/L değerleri arasında anlamlı fark bulunmamıştır.

Sonuç: Bu çalışma bipolar bozukluk manik/depresif dönem hastalarında subklinik enflamasyonun varlığını ve EKT sonrası bu durumun sürdüğünü desteklemektedir. EKT’nin enflamasyon üzerindeki etkilerini belirlemek için geniş ölçekli çalışmalara gerek vardır.

Keywords

Nötrofil, Lenfosit, Monosit, Elektrokonvülsif terapi, Bipolar bozukluk

References

1. Freund N, Juckel G. Bipolar Disorder: Its Etiology and How to Model in Rodents. Psychiatric Disorders. Humana, New York, NY 2019;61-77.
2. Adigüzel V, Özdemir N, Şahin ŞK. Childhood traumas in euthymic patients with bipolar disorder in Eastern Turkey and its relations with suicide risk and aggression. Nordic Journal of Psychiatry. 2019;73(8):490-6.
3. Rosenblat JD, McIntyre RS. Bipolar Disorder and Inflammation. Psychiatr Clin North Am. 2016;39:125-37. doi: 10.1016/j.psc.2015.09.006.
4. Wang TY, Lee SY, Hu MC, Chen SL, Chang YH, Chu CH, et al. More inflammation but less brain-derived neurotrophic factor in antisocial personality disorder. Psychoneuroendocrinology. 2017;85:42-8.
5. Sunbul M, Gerin F, Durmus E, Kivrak T, Sari I, Tigen K, et al. Neutrophil to lymphocyte and platelet to lymphocyte ratio in patients with dipper versus non-dipper hypertension. Clin Exp Hypertens. 2014;36:217-21.
6. Yıldırım ÖT, Akşit E, Aydın F, Aydın AH, Dağtekin E. Can neutrophil to lymphocyte ratio and platelet to lymphocyte ratio be used as biomarkers for non-dipper blood pressure? J Surg Med. 2018;3(1):4-7.
7. Çelen S, Günseren KÖ, Özlülerden Y, Mete A, Tuncay ÖL, Yavaşcaoğlu İ. Does neutrophil-lymphocyte ratio show recurrence in patients who underwent curative resection for non-muscle-invasive bladder cancer? J Surg Med. 2019;3(4):324-7.
8. Krenn-Pilko S, Langsenlehner U, Thurner EM, Stojakovic T, Pichler M, Gerger A, et al. The elevated preoperative platelet-to-lymphocyte ratio predicts poor prognosis in breast cancer patients. Br J Cancer. 2014;13;110:2524-30.
9. Cummings M, Merone L, Keeble C, Burland L, Grzelinski M, Sutton K, et al. Preoperative neutrophil:lymphocyte and platelet:lymphocyte ratios predict endometrial cancer survival. Br J Cancer. 2015;14(113):311-20.
10. Kalelioglu T, Akkus M, Karamustafalioglu N, Genc A, Genc ES, Cansiz A, et al. Neutrophil-lymphocyte and platelet-lymphocyte ratios as inflammation markers for bipolar disorder. Psychiatry Res. 2015;30(228):925-7. doi: 10.1016/j.psychres.2015.05.110.
11. Perugi G, Medda P, Toni C, Mariani MG, Socci C, Mauri M. The Role of Electroconvulsive Therapy (ECT) in Bipolar Disorder: Effectiveness in 522 Patients with Bipolar Depression, Mixed-state, Mania and Catatonic Features. Curr Neuropharmacol. 2017;15:359-371. doi: 10.2174/1570159X14666161017233642.
12. Eroğlu MZ, İçbay E, Tamam L. Bir üniversite hastanesi psikiyatri kliniğinde elektrokonvülzif tedavi uygulanan hastaların demografik ve klinik özellikleri. Dicle Tıp Dergisi. 2012;39(3):371-6.
13. Yrondi A, Sporer M, Péran P, Schmitt L, Arbus C, Sauvaget A. Electroconvulsive therapy, depression, the immune system and inflammation: A systematic review. Brain Stimul. 2018;11:29-51. doi: 10.1016/j.brs.2017.10.013. Epub 2017 Oct 19.
14. Rosenblat JD, McIntyre RS. Are medical comorbid conditions of bipolar disorder due to immune dysfunction? Acta Psychiatr Scand. 2015;132:180-91. doi: 10.1111/acps.12414.
15. Modabbernia A, Taslimi S, Brietzke E, Ashrafi M. Cytokine alterations in bipolar disorder: a meta-analysis of 30 studies. Biol Psychiatry. 2013;1;74:15-25. doi: 10.1016/j.biopsych.2013.01.007.
16. Ortiz-Domínguez A, Hernández ME, Berlanga C, Gutiérrez-Mora D, Moreno J, Heinze G, et al. Immune variations in bipolar disorder: phasic differences. Bipolar Disord. 2007;9:596-602.
17. Brietzke E, Stertz L, Fernandes BS, Kauer-Sant'anna M, Mascarenhas M, Escosteguy Vargas A, et al. Comparison of cytokine levels in depressed, manic and euthymic patients with bipolar disorder. J Affect Disord. 2009;116:214-7.
18. Bond DJ, Andreazza AC, Hughes J, Dhanoa T, Torres IJ, Kozicky JM, et al. Association of peripheral inflammation with body mass index and depressive relapse in bipolar disorder. Psychoneuroendocrinology. 2016;65:76-83. doi: 10.1016/j.psyneuen.2015.12.012.
19. Freire TFV, Rocha NSD, Fleck MPA. The association of electroconvulsive therapy to pharmacological treatment and its influence on cytokines. J Psychiatr Res. 2017 Sep;92:205-11. doi:10.1016/j.jpsychires.2017.05.004.
20. Yrondi A, Sporer M, Péran P, Schmitt L, Arbus C, Sauvaget A. Electroconvulsive therapy, depression, the immune system and inflammation: A systematic review. Brain Stimul. 2018;11:29-51. doi: 10.1016/j.brs.2017.10.013.
21. Bulut M, Altındağ A, Deveci Z, Kaya MC, Bülbül F, Taşkın A, et al. Oxidative parameters in bipolar patients treated with electroconvulsive therapy and pharmacotherapy. Journal of Mood Disorders. 2013;3:93-9.
22. Kargar M, Yoosefi A, Akhondzadeh S, Artonian V, Ashouri A, Ghaeli P. Effect of Adjunctive Celecoxib on BDNF in Manic Patients Undergoing Electroconvulsive Therapy: a Randomized Double Blind Controlled Trial. Pharmacopsychiatry. 2015;48:268-73. doi: 10.1055/s-0035-1559667.
23. Howren MB, Lamkin DM, Suls J. Associations of depression with C-reactive protein, IL-1, and IL-6: a meta-analysis. Psychosom Med. 2009;71(2):171-86. doi: 10.1097/PSY.0b013e3181907c1b.
24. Huang G, Chen H, Wang Q, Hong X, Hu P, Xiao M, et al. High platelet-to-lymphocyte ratio is associated with post-stroke depression. J Affect Disord. 2018;246:105-11. doi: 10.1016/j.jad.2018.12.012.
25. Himmerich H, Bartsch S, Hamer H, Mergl R, Schönherr J, Petersein C, et al. Modulation of cytokine production by drugs with antiepileptic or mood stabilizer properties in anti-CD3-and anti-Cd40-stimulated blood in vitro. Oxid Med Cell Longev. 2014;2014:806162
26. Boufidou F, Nikolaou C, Alevizos B, Liappas IA, Christodoulou GN. Cytokine production in bipolar affective disorder patients under lithium treatment. Journal of Affective Disorders. 2004;82(2):309-13.
27. Mørch RH, Dieset I, Færden A, Hope S, Aas M, Nerhus M, Aukrust P. Inflammatory evidence for the psychosis continuum model. Psychoneuroendocrinology. 2016;67:189-97.

Details

Primary Language	English
Subjects	Psychiatry
Journal Section	Research article
Authors	Şengül Kocamer ŞAHİN GAZİANTEP ÜNİVERSİTESİ, TIP FAKÜLTESİ 0000-0002-5371-3907 Türkiye Celal YAŞAMALI This is me GAZİANTEP ÜNİVERSİTESİ, TIP FAKÜLTESİ 0000-0002-2813-2270 Türkiye Muhammet Berkay ÖZYÜREK This is me GAZİANTEP ÜNİVERSİTESİ, TIP FAKÜLTESİ 0000-0002-7016-1411 Gülçin ELBOĞA GAZİANTEP ÜNİVERSİTESİ, TIP FAKÜLTESİ 0000-0003-3903-1835 Türkiye Abdurrahman ALTINDAĞ GAZİANTEP ÜNİVERSİTESİ, TIP FAKÜLTESİ 0000-0001-5531-4419 Türkiye Enes ELMALI This is me GAZİANTEP ÜNİVERSİTESİ, TIP FAKÜLTESİ 0000-0002-5425-1150 Türkiye Handan DEMİRBAŞ This is me GAZİANTEP ÜNİVERSİTESİ, TIP FAKÜLTESİ 0000-0002-0894-5565 Türkiye
Publication Date	November 1, 2019
Published in Issue	Year 2019, Volume 3, Issue 11

Cite

Bibtex	@research article { josam637840, journal = {Journal of Surgery and Medicine}, issn = {}, eissn = {2602-2079}, address = {jsurgmed@gmail.com}, publisher = {Fatih BAŞAK}, year = {2019}, volume = {3}, pages = {793 - 795}, doi = {10.28982/josam.637840}, title = {The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders}, key = {cite}, author = {Şahin, Şengül Kocamer and Yaşamalı, Celal and Özyürek, Muhammet Berkay and Elboğa, Gülçin and Altındağ, Abdurrahman and Elmalı, Enes and Demirbaş, Handan} }
APA	Şahin, Ş. K. , Yaşamalı, C. , Özyürek, M. B. , Elboğa, G. , Altındağ, A. , Elmalı, E. & Demirbaş, H. (2019). The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders . Journal of Surgery and Medicine , 3 (11) , 793-795 . DOI: 10.28982/josam.637840
MLA	Şahin, Ş. K. , Yaşamalı, C. , Özyürek, M. B. , Elboğa, G. , Altındağ, A. , Elmalı, E. , Demirbaş, H. "The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders" . Journal of Surgery and Medicine 3 (2019 ): 793-795 <https://jsurgmed.com/en/pub/issue/49829/637840>
Chicago	Şahin, Ş. K. , Yaşamalı, C. , Özyürek, M. B. , Elboğa, G. , Altındağ, A. , Elmalı, E. , Demirbaş, H. "The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders". Journal of Surgery and Medicine 3 (2019 ): 793-795
RIS	TY - JOUR T1 - The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders AU - Şengül Kocamer Şahin , Celal Yaşamalı , Muhammet Berkay Özyürek , Gülçin Elboğa , Abdurrahman Altındağ , Enes Elmalı , Handan Demirbaş Y1 - 2019 PY - 2019 N1 - doi: 10.28982/josam.637840 DO - 10.28982/josam.637840 T2 - Journal of Surgery and Medicine JF - Journal JO - JOR SP - 793 EP - 795 VL - 3 IS - 11 SN - -2602-2079 M3 - doi: 10.28982/josam.637840 UR - https://doi.org/10.28982/josam.637840 Y2 - 2019 ER -
EndNote	%0 Journal of Surgery and Medicine The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders %A Şengül Kocamer Şahin , Celal Yaşamalı , Muhammet Berkay Özyürek , Gülçin Elboğa , Abdurrahman Altındağ , Enes Elmalı , Handan Demirbaş %T The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders %D 2019 %J Journal of Surgery and Medicine %P -2602-2079 %V 3 %N 11 %R doi: 10.28982/josam.637840 %U 10.28982/josam.637840
ISNAD	Şahin, Şengül Kocamer , Yaşamalı, Celal , Özyürek, Muhammet Berkay , Elboğa, Gülçin , Altındağ, Abdurrahman , Elmalı, Enes , Demirbaş, Handan . "The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders". Journal of Surgery and Medicine 3 / 11 (November 2019): 793-795 . https://doi.org/10.28982/josam.637840
AMA	Şahin Ş. K. , Yaşamalı C. , Özyürek M. B. , Elboğa G. , Altındağ A. , Elmalı E. , Demirbaş H. The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders. J Surg Med. 2019; 3(11): 793-795.
Vancouver	Şahin Ş. K. , Yaşamalı C. , Özyürek M. B. , Elboğa G. , Altındağ A. , Elmalı E. , Demirbaş H. The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders. Journal of Surgery and Medicine. 2019; 3(11): 793-795.
IEEE	Ş. K. Şahin , C. Yaşamalı , M. B. Özyürek , G. Elboğa , A. Altındağ , E. Elmalı and H. Demirbaş , "The effect of electroconvulsive therapy on subclinical inflammation in bipolar disorders", Journal of Surgery and Medicine, vol. 3, no. 11, pp. 793-795, Nov. 2019, doi:10.28982/josam.637840

Download Cover Image

Article Files

Full Text

The DNS issue is resolved. jsurgmed.com and current publication are fully accessible.

To use the submission system properly, please use one of the following browsers, Chrome or Firefox, with the latest updates.
If you experience problems, it may be necessary to clear the browser cache and history; and disable blocker extensions, i.e., uBlock, of the browsers
Mobile phones are not recommended, please use a personal computer.