The benefits and costs of changing treatment technique in electroconvulsive therapy due to insufficient improvement of a major depressive episode

Abstract

Background: Electroconvulsive therapy (ECT) technique is often changed after insufficient improvement, yet there has been little research on switching strategies.

Objective: To document clinical outcome in ECT nonresponders who were received a second course using high dose, brief pulse, bifrontotemporal (HD BP BL) ECT, and compare relapse rates and cognitive effects relative to patients who received only one ECT course and as a function of the type of ECT first received.

Methods: Patients were classified as receiving Weak, Strong, or HD BP BL ECT during three randomized trials at Columbia University. Nonresponders received HD BP BL ECT. In a separate multi-site trial, Optimization of ECT, patients were randomized to right unilateral or BL ECT and nonresponders also received further treatment with HD BP BL ECT.

Results: Remission rates with a second course of HD BP BL ECT were high in ECT nonresponders, approximately 60% and 40% in the Columbia University and Optimization of ECT studies, respectively. Clinical outcome was independent of the type of ECT first received. A second course with HD BP BL ECT resulted in greater retrograde amnesia immediately, two months, and six months following ECT.

Conclusions: In the largest samples of ECT nonresponders studied to date, a second course of ECT had marked antidepressant effects. Since the therapeutic effects were independent of the technique first administered, it is possible that many patients may benefit simply from longer courses of ECT. Randomized trials are needed to determine whether, when, and how to change treatment technique in ECT.

Keywords: Electroconvulsive therapy (ECT); Relapse; Retrograde amnesia; Switching strategy.

Conflict of interest statement

Declaration of Conflicts of Interest

Drs. Prudic, Nobler, Haskett, and Rosenquist have no conflicts of interest to declare.

Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.

Figures

Figure 1.

Patient flow through Mode 1 and Mode 2 treatment with ECT and one-year monitoring for relapse in the Columbia University studies.

Figure 2.

Hamilton Rating Scale for Depression Scores (mean ± SE) before, during, and after Mode 1 (Randomized Phase) and after Mode 2 treatment with ECT, for groups that received weak or strong forms of ECT or high dose bilateral ECT in Mode 1. Asterisks indicate that the three Mode 1 treatment groups differed significantly (P

Figure 3.

Kaplan-Meier estimates of the proportion of patients who remained well during the year following ECT as a function of responding to Mode 1 or Mode 2.