Electroconvulsive therapy (ECT) is usually reserved for difficult-to-treat
depression patients who are not suitable for or have failed to respond to
antidepressant medications. However, patients who have failed at least one
adequate course of medication have a 1 in 3 chance of relapse within a week
after responding to ECT.
A study published online in the Journal of Clinical Psychiatry on
January 13 presented new data analyses from a large multicenter clinical trial
on the long-term effectiveness of ECT conducted from 1997 to 2004. The trial
was conducted by the Consortium for Research on Electroconvulsive Therapy
(CORE), a group of medical centers across the country that have been
collaborating on clinical research to investigate ECT effectiveness and
relapse prevention in the real-world patient-care setting.
In the clinical trial, 531 patients with unipolar depression received ECT
three times a week until they either reached remission or completed 10 ECT
sessions without remission. Patients were assessed at baseline and after each
ECT session.
The criterion for remission was achieving a 60 percent reduction from
baseline in the 24-item Hamilton Rating Scale for Depression
(HAM-D24) score and two consecutive assessments in which the scores
were no more than 10, with no more than a three-point drop between the two
assessments to ensure the response was stable. At baseline each patient was
questioned about past treatment to determine whether he or she had had a
previous trial of antidepressant treatment with adequate dosage and
duration.FIG1
The 341 patients who achieved remission waited for one week before they
were randomized to the long-term phase of the trial, which compared the
effectiveness of maintenance ECT with that of pharmacotherapy. This study
examined only the subsample of 146 patients who reached remission within 10
sessions, had no psychotic features, and provided treatment history at
baseline.
During the one-week interim period when patients in remission had no
treatment for depression, nearly a third (31.4 percent) of the 105
nonpsychotic patients with a history of medication resistance relapsed,
meaning that their HAM-D24 score rose back above 10. This relapse
rate was significantly higher than the 9.8 percent rate in the 41 patients who
did not have a history of medication resistance.
The study findings suggested "the fragile nature of ECT-induced
remissions in previously medication-resistant patients," the researchers
concluded.
At the end of the interim week, 73 patients who were still in remission
were randomized to receive either pharmacotherapy or maintenance ECT for the
next six months. About 48 percent of these patients relapsed during the
six-month period, 40 percent did not relapse, and the remainder dropped out of
the study.
By the end of the six-month maintenance period, 53 percent of patients with
a history of medication resistance and 38 percent of patients without such a
history relapsed despite treatment. This difference, however, was not
statistically significant.
Keith Rasmussen, M.D., a psychiatrist in the Department of Psychiatry and
Psychology at the Mayo Clinic and the lead author of the study, recommended
that psychiatrists should not "be dissuaded from doing ECT in a patient
who is medication refractory, but [should] be aggressive in planning the
treatment-continuation strategies."
These strategies, he noted, "would include starting medications
immediately after the end of ECT and possibly before it," he told
Psychiatric News.
The study was funded by grants from the National Institute of Mental
Health.
An abstract of "Is Baseline Medication Resistance Associated
With Potential for Relapse After Successful Remission of a Depressive Episode
With ECT? Data From the Consortium for Research on Electroconvulsive Therapy
(CORE)" is posted at<www.psychiatrist.com/abstracts/abstracts.asp?abstract=oap/ej08m04092.htm>.▪