8 opinions from an ECT expert about 2 major studies on ECT for Depression

On psychiatrictimes.com Prof Max Fink discusses the 2 most important articles on continuation therapy after ECT for depression. ECT is very effective in the treatment of depression even if several antidepressants have failed. He discusses a large, government-supported, collaborative study led by the Columbia University Consortium (CUC), patients with unipolar major depression that had failed to respond to multiple trials of medications were treated with ECT to clinical remission and then randomly assigned to one of three continuation treatments: placebo, nortriptyline alone, or the combination of nortriptyline and lithium.

The other important trials is the multi site Consortium for Research in ECT (CORE) collaborative study that used the same populations with the same inclusion and exclusion criteria, evaluations, and time periods as the CUC study. After remission, the patients were randomly assigned to continuation treatment with the same combination of lithium and nortriptyline or with ECT.

The six-month relapse rates for the two treatments were not statistically different from that of the lithium and nortriptyline combination in the CUC study

His conclusions:
1. Efficacy: ECT was effective in both studies. ECT compared favorably with the STAR*D study of patients with nonpsychotic major depression.

2. Psychotic Depression: 95% of the patients who had psychosis and depression remitted compared with 83% of patients who had nonpsychotic depression.

3. Suicide: In the CORE study, 29.5% of the patients expressed suicidal thoughts or reported suicidal acts at baseline. The HAM-D scores for suicidal intent were reduced to zero in 38% of the patients after one week of treatment, in 61% after two weeks, and in 81% at the end of the course. These findings are supported by comparable CUC data.

4. Prior treatment: In the CORE study, the adequacy of prior treatment bore no relation to treatment efficacy, a finding that is confirmed in other studies.

5. Elderly: older patients with depression exhibit better clinical outcomes than younger patients when treated using ECT

6. Relapse rates after successful ECT are reduced by either the combination of lithium and nortriptyline or by continuation ECT.

7. Continuation therapy: the combination of lithium and nortriptyline, both monitored with serum blood levels, is the preferred medication when continuation ECT is not available or is refused.

8. Electrode placement: bilateral electrode placement and half-age dosing estimates, monitored by EEG adequacy, ensures greater efficacy for the first treatment and overall with fewer treatments

Articles used:
1. Sackeim HA, Haskett RF, Mulsant BH, et al. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. JAMA. 2001;285:1299-1307.
2. Kellner CH, Knapp RG, Petrides G, et al. Continuation ECT versus pharmacotherapy for relapse prevention in major depression: a multi-site study from CORE. Arch Gen Psychiatry. 2006;63:1337-1344.