Majority of patients at the severe end of depression spectrum experience repeated relapses. ECT is effective as an acute treatment. Continuation of antidepressant is the standard treatment to prevent relapse. Addition of lithium or continuation ECT are other strategies to reduce relapse. Combination of ongoing ECT with antidepressants is supported by retrospective studies and a small RCT.Larger RCTs are required to see whether this is in fact true.
Axel Nordenskjo and team report the results of an RCT asking the question whether relapse prevention with continuation ECT plus pharmacotherapy is more effective than pharmacotherapy alone after a course of ECT for depression.
Patients were randomized to continuation ECT received weekly ECT for 6 weeks and thereafter every 2 weeks for 46 additional weeks, a total of 29 ECTs for the full year. Unilateral ultrabrief pulse ECT was used. At the first continuation ECT session, the seizure threshold was measured and at the proceeding sessions, an electrical dose 6 times the seizure threshold was used. All patients received individualized medication. Venlafaxine was considered first choice, and lithium augmentation was offered to all patients.antipsychotic medication was allowed. Anticonvulsant drugs were not used.The primary outcome measure was time to relapse.
1-year relapse rate was 61% for the patients treated with pharmacotherapy and 32% for the patients treated with ECT plus pharmacotherapy (P = 0.036). 36% of the patients in the pharmacotherapy group and 20% in the pharmacotherapy-plus-ECT group required inpatient care during follow-up.
For patients without relapses, there were no statistically significant differences in the developments of the measures of cognitive function and subjective memory between the patients randomized to the ECT-plus-pharmacotherapy group or the pharmacotherapy-alone group.
Limitations: 90 patients were considered necessary by power calculations. only 56 were recruited and this limit the strength of the findings. This study was non blinded (raters were not blind). The tests used for cognitive assessments might not detect small effects . Patients were receiving medications of wide heterogeneity.
Conclusions: continuation ECT with pharmacotherapy might be an effective option in some depressed patients.
Summary of the article:
Nordenskjöld A, von Knorring L, Ljung T, Carlborg A, Brus O, Engström I. J ECT. 2013 Jun;29(2):86-92.