Psychotic Depression, ECT and Continuation Treatment in the Elderly
After remission on ECT for psychotic depression the combination of nortriptyline and ECT prevented relapse or recurrence in 11 of 16 patients during follow-up of 2 years, of the 17 nortriptyline treated patients only 5 were considered without relapse or recurrence. The mean survival time until relapse was 23 months in the ECT with nortriptyline group and 16 months in the nortriptyline group.
ECT or electroshock is the only treatment in psychiatry that is stopped when successful. Usually treatment is continued with an antidepressant or the combination of an antidepressant with lithium. Tricyclic antidepressants are mostly used because most research on continuation treatment after ECT is done with these antidepressants.
Most research is done with adults not specifically with elderly. When a severely depressed elderly is admitted to our ward and recovers I usually advice them not to stop their antidepressants. I have seen to many relapse when tapering or stopping their antidepressants. There time left is to valuable to spent on psychiatric wards.
A severe form of depression, psychotic depression usually warrants ECT treatment in the elderly. This severe form of depression leads to deterioration fast which can be interrupted effectively by ECT.
In this research a group of elderly with psychotic depression was treated with ECT and nortrityline. When remitted (33/38, 86.8%) they were randomized single blind to continuation ECT with nortriptyline or nortriptyline alone. The high percentage of remitters is no exception with ECT for psychotic depression.
The combination of continuation ECT with nortriptyline is exceptional. In adults a recent trial comparing continuation ECT to nortriptyline with lithium showed no significant difference in relapse during a 6 month follow-up. You can read about this study published in the Archives of General Psychiatry in a post on this blog. Nevertheless both treatments were well tolerated although cognitive side effects were not adequately monitored.
Other limitations of this study are the small sample size, only 14 had initially received pharmacotherapy for their episode before ECT.
Navarro, V. (2008). Continuation/Maintenance Treatment with Nortriptyline Versus Combined
Nortriptyline and ECT in Late-Life
Psychotic Depression: A Two-Year Randomized Study. American Journal of Geriatric Psychiatry, 16(6), 498-505.
July 4, 2008 @ 3:48 pm
Hey Dr. Shock,
Is there a reason that most research is done with tricyclic antidepressants on continuation ECT rather than the newer ones? And is continuation ECT different from maintanance ECT?
I’m just curious! I had ECT a month ago, 5 treatmts., and am fascinated with learning about it. I begin again Monday for another series; I guess I quit too soon!
Anyway, I enjoy your blog.
July 4, 2008 @ 3:53 pm
Yes, tricyclic antidepressants are used in most studies about continuation treatment after ECT. SSRIs haven’t been studied at all after ECT. TCA’s are believed to be more appropriate with severe depression.
The difference between continuation treatment and maintenance treatment is arbitrary but continuation treatment is to prevent relapse and maintenance treatment is to prevent recurrence. The continuation phase is 6 months and maintenance treatment after 6 months.
Regards Dr Shock
July 8, 2008 @ 4:14 am
I had 10 treatments, and I would never ever do it again. It didn’t help me at all, only gave me memory loss…Mary
November 1, 2008 @ 11:50 pm
I would be interested in what you would say about giving a 96 year old woman ECT. We are speaking here of someone who has suffered recurring bouts of depression throughout her entire adult life and who has recently been termed “bipolar.” Recently she has been violent with staff and her fellow inmates at her long term care facility. One argument offered for the ECT is that her liver would be compromised by ongoing medications.
It seems to me that there are risks with both treatments but that there may be greater risks to the brain and body through ECT. I am not a doctor, but I am a concerned son who would hesitate to give consent to such an extremely violent treatment. Which do you think offers the greater risk of a detrimental outcome?
November 2, 2008 @ 11:46 am
I can’t give individual advices since I don’t know the patient nor have seen her. All I can tell you that her age is not a contraindication for ECT.
Regards Dr Shock