Effects of maintenance electroconvulsive therapy on cognitive functions

The Efficacy and Tolerability of Continuation and Maintenance Electroconvulsive Therapy for Depression: A Systematic Review of Randomized and Observational Studies

ABSTRACT

Electroconvulsive therapy (ECT) is a highly effective treatment for severe and treatment-resistant depression, but relapse rates remain high despite maintenance pharmacotherapy. Continuation or maintenance ECT (C/M-ECT) offers the potential to prevent relapses in the most unwell patients, but there remains disagreement among guidelines regarding its efficacy and tolerability. This review aims to summarize and assess the current evidence for the efficacy and tolerability of continuation and maintenance ECT for depression, including data from randomized and observational studies, which included an appropriate control group. Twenty studies were found meeting inclusion criteria. There was evidence from 14 studies suggesting that relapse rates are reduced in those receiving C/M-ECT. There was evidence from 6 studies suggesting that C/M-ECT had no effect on global cognitive function. Detailed neuropsychological testing was limited, but within studies that assessed specific cognitive domains, there was not consistent evidence for deficits in C/M-ECT compared with the control group. The certainty of evidence across outcomes was low or very low because of inclusion of observational studies, heterogeneity of study design, and patient populations. The findings add further weight to evidence suggesting that C/M-ECT is a viable treatment option to prevent relapse in severe depression and provides clinicians with further evidence for the benefits and risks of C/M-ECT when discussing treatment options with patients. Future research should focus on randomized or well-designed prospective studies with sufficient follow-up to determine longer-term outcomes, while including a standardized, detailed neurocognitive battery to assess potential adverse effects.

Electroconvulsive therapy in the continuation and maintenance treatment of depression: Systematic review and meta-analyses

OBJECTIVE

Acute course of electroconvulsive therapy is effective in inducing remission from depression, but recurrence rate is unacceptably high following termination of electroconvulsive therapy despite continued pharmacotherapy. Continuation electroconvulsive therapy and maintenance electroconvulsive therapy have been studied for their efficacy in preventing relapse and recurrence of depression. The purpose of this meta-analysis was to examine the efficacy of continuation electroconvulsive therapy and maintenance electroconvulsive therapy in preventing relapse and recurrence of depression in comparison to antidepressant pharmacotherapy alone.

METHODS

We searched MEDLINE, Embase, PsycINFO, clinicaltrials.gov and Cochrane register of controlled trials from the database inception to December 2016 without restriction on language or publication status for randomized trials of continuation electroconvulsive therapy and maintenance electroconvulsive therapy. Two independent Cochrane reviewers extracted the data in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews and meta-analyses. The risk of bias was assessed using four domains of the Cochrane Collaboration Risk of Bias Tool. Outcomes were pooled using random effect model. The primary outcome was relapse or recurrence of depression.

RESULTS

Five studies involving 436 patients were included in the meta-analysis. Analysis of the pooled data showed that continuation electroconvulsive therapy and maintenance electroconvulsive therapy, both with pharmacotherapy, were associated with significantly fewer relapses and recurrences than pharmacotherapy alone at 6 months and 1 year after a successful acute course of electroconvulsive therapy (risk ratio = 0.64, 95% confidence interval = [0.41, 0.98], p = 0.04, risk ratio = 0.46, 95% confidence interval = [0.21, 0.98], p = 0.05, respectively). There was insufficient data to perform a meta-analysis of stand-alone continuation electroconvulsive therapy or maintenance electroconvulsive therapy beyond 1 year.

CONCLUSION

There are only a few randomized trials of continuation electroconvulsive therapy and maintenance electroconvulsive therapy. The preliminary and limited evidence suggests the modest efficacy of continuation electroconvulsive therapy and maintenance electroconvulsive therapy with concomitant pharmacotherapy in preventing relapse and recurrence of depressive episodes for 1 year after the remission of index episode with the acute course of electroconvulsive therapy.

The maintenance of modified electroconvulsive therapy combined with risperidone is better than risperidone alone in preventing relapse of schizophrenia and improving cognitive function

ABSTRACT Objective To evaluate the effect of maintenance modified electroconvulsive therapy (MECT) on schizophrenic patients. Methods From June 2012 to June 2014, 62 patients with schizophrenia, who had recovered from a successful course of acute MECT, were recruited. Thirty-one patients received maintenance MECT and risperidone, as the experimental group. Another 31 patients were enrolled in the control group, and received risperidone only. The effects on cognitive functions, clinical symptoms and relapse rate were determined. Results Patients in the experimental group had a lower relapse rate and longer relapse-free survival time than the controls. Relative to the baseline evaluation, patients showed statistically significant improvement in verbal memory and visual memory. At the final assessment, the scores of verbal and visual memory were remarkably lower in the experimental group than the controls but there was no significant difference in other tests. Conclusion Maintenance MECT plus medication is superior to medication alone in preventing relapse and improving cognitive function.

Evaluation of cumulative cognitive deficits from electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is the most effective acute treatment for severe depression, but widely held concerns about memory problems may limit its use.

AIMS

To find out whether repeated or maintenance courses of ECT cause cumulative cognitive deterioration.

METHOD

Analysis of the results of 10 years of cognitive performance data collection from patients who have received ECT. The 199 patients had a total of 498 assessments, undertaken after a mean of 15.3 ECT sessions (range 0-186). A linear mixed-effect regression model was used, testing whether an increasing number of ECT sessions leads to deterioration in performance.

RESULTS

The total number of previous ECT sessions had no effect on cognitive performance. The major factors affecting performance were age, followed by the severity of depression at the time of testing and the number of days since the last ECT session.

CONCLUSIONS

Repeated courses of ECT do not lead to cumulative cognitive deficits. This message is reassuring for patients, carers and prescribers who are concerned about memory problems and confusion during ECT.

Electroconvulsive therapy: a life course approach for recurrent depressive disorder

We describe the case of an 89-year-old woman (deceased) with a 60-year history of recurrent depressive disorder treated with electroconvulsive therapy (ECT). It is estimated that she received up to 400 ECTs over her life course as her symptoms would not respond to oral medication. Despite extensive exposure to ECT, there was only minimal cognitive impairment and an excellent safety record, even in later life, as she became increasingly frail from multiple comorbidities. Over the years, there has been a drive to reduce the frequency of ECT administration. However, this case illustrates how in some patients ECT may be vital for acute episodes of severe depression as well as for maintenance therapy. This case report adds to observational evidence that maintenance ECT may be an underused treatment for recurrent depression and also recommends that greater emphasis be given to incorporating carers' views when planning individualised treatment approaches.

Is there a decline in cognitive functions after combined electroconvulsive therapy and antipsychotic therapy in treatment-refractory schizophrenia?

An analysis of literature shows that there is still little evidence concerning the efficacy of electroconvulsive therapy (ECT) combined with antipsychotic therapy in a group of treatment-resistant schizophrenia patients. More precisely, its influence on cognitive functions is still equivocal. The aim of this study was to assess the influence of ECT combined with antipsychotic therapy on working memory, attention, and executive functions in a group of treatment-refractory schizophrenia patients. Twenty-seven patients completed the study: 14 men and 13 women, aged 21 to 55 years (mean age, 32.8 years), diagnosed with treatment-resistant schizophrenia. Each patient underwent a course of ECT sessions and was treated with antipsychotic medications. Before the ECT and within 3 days after the last ECT session, the participants were assessed with the following neuropsychological tests: Trail Making Test (TMT) and Wisconsin Cart Sorting Test (WCST). There were no significant differences in the TMT and WCST results after combined ECT and antipsychotic therapy in treatment-refractory schizophrenia patients. According to the results of the neuropsychological tests, there was no decline in attention, executive functions, or working memory. The current study shows no significant difference in attention, working memory, or executive functions after treatment with a combination of electroconvulsive and antipsychotic therapy. This suggests that combined electroconvulsive therapy may not have a negative influence on the neuropsychological functioning of patients with treatment resistant schizophrenia.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders. part 2: maintenance treatment of major depressive disorder-update 2015

These guidelines for the treatment of unipolar depressive disorders systematically review available evidence pertaining to the biological treatment of patients with major depression and produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians assessing and treating patients with these conditions. The relevant data have been extracted primarily from various treatment guidelines and panels for depressive disorders, as well as from meta-analyses/reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into five levels of evidence (CE A-F) and five levels of recommendation grades (RG 1-5). This second part of the WFSBP guidelines on depressive disorders covers the management of the maintenance phase treatment, and is primarily concerned with the biological treatment (including pharmacological and hormonal medications, electroconvulsive therapy and other brain stimulation treatments) of adults and also, albeit to a lesser extent, children, adolescents and older adults.

Maintenance electroconvulsive therapy up to 12 years

BACKGROUND

Maintenance electroconvulsive therapy (m-ECT) is effective in preventing recurrences of depressive episodes. There is little information on long-term m-ECT extending over several years and its impact on cognitive functions. This study was an attempt to determine the efficacy and side effects of long-term m-ECT.

METHOD

Depressive episodes and admissions before m-ECT for a period equal to the duration of m-ECT and during m-ECT were compared using medical records. Cognitive functions assessed by Mini-Mental State Examination (MMSE) before and after m-ECT were compared along with the review of Neuropsychiatry Unit Cognitive Assessment Tool (NUCOG).

RESULTS

17 patients had m-ECT that extended from 6 to 153 months (mean 39, SD=44.46). The average number of episodes before and during m-ECT was 2.47 (SD=2.23) and 0.88 (SD=1.31) respectively (Wilcoxon ranked test Z=3.06, r=0.55, two-tailed p=0.002). Average number of admissions dropped from 2.05 (SD=1.88) to 0.23 (SD=0.43) during m-ECT (Z=3.471, r=0.71, p=0.001). The average time to recurrence was 24.24 months (SD=25.20) with longest depression free survival of 105 months. There was no significant difference in MMSE score before and after the commencement m-ECT or progressive deterioration in NUCOG score.

LIMITATIONS

This study was limited by retrospective nature of data collection, small sample size, confounding effects of antidepressants along with m-ECT and absence of a highly sensitive cognitive screening tool that can capture all types of cognitive impairments following m-ECT.

CONCLUSIONS

In a naturalistic setting the efficacy of m-ECT may extend over several years while cognitive functions remain largely unaffected.

Efficacy and safety of continuation and maintenance electroconvulsive therapy in depressed elderly patients: a systematic review

BACKGROUND

Electroconvulsive therapy (ECT) is the most efficacious treatment in severely depressed elderly patients. Relapse and recurrence of geriatric depression after recovery is an important clinical issue, which requires vigorous and safe treatment in the long term. Continuation or maintenance ECT (M-ECT) may play an important role in this respect.

METHODS

In this systematic search, we evaluate the efficacy and safety of M-ECT in preventing depressive relapse in patients age 55 or older. Computer databases were searched for relevant literature published from 1966 until August 2010 with additional references.

RESULTS

Twenty-two studies met the search criteria including three randomized clinical trials. M-ECT was studied in nine studies exclusively in the elderly patients.

CONCLUSIONS

Research on this clinically important topic is sparse. On the basis of available literature, M-ECT is probably as effective as continuation medication in severely depressed elderly patients after a successful course of ECT and is generally well tolerated. To date, methodologically sound studies, which take into account important issues in geriatric depression like cognition, comorbidity, and clinical parameters, are lacking.

Two-year follow-up of cognitive functions in schizophrenia spectrum disorders of adolescent patients treated with electroconvulsive therapy

OBJECTIVE

The aim of the current study was to investigate the long-term cognitive effects of electroconvulsive therapy (ECT) in a sample of adolescent patients in whom schizophrenia spectrum disorders were diagnosed.

METHODS

The sample was composed of nine adolescent subjects in whom schizophrenia or schizoaffective disorder was diagnosed according to DSM-IV-TR criteria on whom ECT was conducted (ECT group) and nine adolescent subjects matched by age, socioeconomic status, and diagnostic and Positive and Negative Syndrome Scale (PANSS) total score at baseline on whom ECT was not conducted (NECT group). Clinical and neuropsychological assessments were carried out at baseline before ECT treatment and at 2-year follow-up.

RESULTS

Significant differences were found between groups in the number of unsuccessful medication trials. No statistically significant differences were found between the ECT group and the NECT group in either severity as assessed by the PANSS, or in any cognitive variables at baseline. At follow-up, both groups showed significant improvement in clinical variables (subscales of positive, general, and total scores of PANSS and Clinical Global Impressions-Improvement). In the cognitive assessment at follow-up, significant improvement was found in both groups in the semantic category of verbal fluency task and digits forward. However, no significant differences were found between groups in any clinical or cognitive variable at follow-up. Repeated measures analysis found no significant interaction of time×group in any clinical or neuropsychological measures.

CONCLUSIONS

The current study showed no significant differences in change over time in clinical or neuropsychological variables between the ECT group and the NECT group at 2-year follow-up. Thus, ECT did not show any negative influence on long-term neuropsychological variables in our sample.

Continuation and maintenance electroconvulsive therapy for mood disorders: review of the literature

BACKGROUND

Electroconvulsive therapy (ECT) is a highly effective treatment for mood disorders. Continuation ECT (C-ECT) and maintenance ECT (M-ECT) are required for many patients suffering from severe and recurrent forms of mood disorders. This is a review of the literature regarding C- and M-ECT.

METHODS

We conducted a computerized search using the words continuation ECT, maintenance ECT, depression, mania, bipolar disorder and mood disorders. We report on all articles published in the English language from 1998 to 2009.

RESULTS

We identified 32 reports. There were 24 case reports and retrospective reviews on 284 patients. Two of these reports included comparison groups, and 1 had a prospective follow-up in a subset of subjects. There were 6 prospective naturalistic studies and 2 randomized controlled trials.

CONCLUSIONS

C-ECT and M-ECT are valuable treatment modalities to prevent relapse and recurrence of mood disorders in patients who have responded to an index course of ECT. C-ECT and M-ECT are underused and insufficiently studied despite positive clinical experience of more than 70 years. Studies which are currently under way should allow more definitive recommendations regarding the choice, frequency and duration of C-ECT and M-ECT following acute ECT.

Use of continuation or maintenance electroconvulsive therapy in adolescents with severe treatment-resistant depression

Retrospective data are presented for 6 adolescents ranging in age from 14 to 17 years, who were diagnosed with severe treatment-resistant major depression (TRD). Subjects were treated with one or more index courses of electroconvulsive therapy (ECT) followed by continuation ECT (C-ECT, up to 6 months of ECT) or maintenance ECT (M-ECT; ECT beyond 6 months) when necessary. Electroconvulsive therapy was continued until remission or until minimal residual symptoms were evident. Pharmacotherapy and psychotherapy were reintroduced during C-ECT or M-ECT. Premorbid functioning was achieved by 5 of 6 cases. Cognitive deficits were not evident. In fact, comparison of pre-ECT and post-ECT neuropsychological functioning revealed a trend toward improved auditory and verbal memory on most of the results. We concluded that C-ECT and M-ECT are useful and safe treatment strategies for selected adolescents with severe treatment-resistant depression, and symptom remission may be achieved without experiencing cognitive impairment.

A review of continuation electroconvulsive therapy: application, safety, and efficacy

Electroconvulsive therapy (ECT) is a neurostimulation therapeutic intervention that is highly effective and frequently used to treat certain psychiatric conditions, particularly major depressive disorder. Despite its high efficacy, a major limitation of ECT is the significant rate at which patients relapse after treatment. Providing additional ECT treatments after completion of a short-term course of ECT, referred to as continuation ECT (C-ECT), is a strategy used to reduce the risk of relapse. Specifically, C-ECT involves the administration of additional ECT treatments during the 6-month period after remission. This article summarizes the available literature regarding C-ECT including indication for use, patient selection, treatment guidelines/parameters, and safety. The efficacy of C-ECT is also discussed, with a focus on major depressive disorder and schizophrenia. On the basis of the current literature, indications for use and patient selection for C-ECT are predominately similar to those for a short-term ECT course. The treatment guidelines/parameters for C-ECT are recommended to be consistent with the parameters used to achieve remission, with the exception of greater intertreatment intervals during C-ECT. Although adverse cognitive effects can occur during C-ECT, the risk and severity of cognitive impairment are generally low, possibly because of the greater intertreatment intervals. Most research supports the use of C-ECT to prolong remission; however, methodologic limitations mitigate firm conclusions and generalizability of these findings. Nonetheless, the available evidence supports the use of C-ECT as a safe and effective method in relapse prevention.

Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. IV. Neurostimulation therapies

BACKGROUND

In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. There is renewed interest in refined approaches to brain stimulation, particularly for treatment resistant major depressive disorder (MDD).

METHODS

The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support. This section on "Neurostimulation Therapies" is one of 5 guidelines articles.

RESULTS

Among the four forms of neurostimulation reviewed in this section, electroconvulsive therapy (ECT) has the most extensive evidence, spanning seven decades. Repetitive transcranial magnetic (rTMS) and vagus nerve stimulation (VNS) have been approved to treat depressed adults in both Canada and the United States with a much smaller evidence base. There is also emerging evidence that deep brain stimulation (DBS) is effective for otherwise treatment resistant depression, but this is an investigational approach in 2009.

LIMITATIONS

Compared to other modalities for the treatment of MDD, the data based is limited by the relatively small numbers of randomized controlled trials (RCTs) and small sample sizes.

CONCLUSIONS

There is most evidence to support ECT as a first-line treatment under specific circumstances and rTMS as a second-line treatment. Evidence to support VNS is less robust and DBS remains an investigational treatment.

Individualized continuation electroconvulsive therapy and medication as a bridge to relapse prevention after an index course of electroconvulsive therapy in severe mood disorders: a naturalistic 3-year cohort study

Electroconvulsive therapy (ECT) is recognized as an effective acute treatment for mood disorders but is associated with high risk of relapse. To minimize this risk, we introduced as a routine individually tapered continuation ECT with concomitant medication (C-ECT + Med) after an index series in January 2000. In August 2002, a chart review of all patients (n = 41) who had received C-ECT + Med for more than 4 months was carried out. Sixteen patients also participated in an extensive interview. Mean duration of administered C-ECT at follow-up was 1 year, but for most patients (63%), C-ECT had been terminated. For 49% of patients, adjustments between ECT sessions had been made due to early signs of relapse. Two weeks was the most common interval between sessions for patients with ongoing C-ECT. The frequency of lithium-treated patients had increased from 12% before index to 41% during C-ECT. However, the rated response to the drug varied. Need for hospital care 3 years before and after the initiation of C-ECT + Med was compared in a second evaluation of the cohort. The number of patients hospitalized, number of admissions, and total days in hospital were all significantly reduced. Hospital days were reduced by 76% (P < 0.001). Three patients with previously cumulative years in hospital are described as case vignettes after 6 years with no or minimal need for further hospitalization. This study supports previous findings that individually tapered C-ECT + Med can maintain initial response to ECT and serve as a bridge to long-term relapse prevention.

The effects of ECT on cognitive functioning in the elderly: a review

BACKGROUND

Electroconvulsive therapy (ECT) as a single course or in maintenance form (M-ECT) is an effective treatment in depressed elderly. However, ECT may have adverse effects on cognition.

OBJECTIVE

To review all studies from 1980-2006 on ECT and cognition in the elderly with a minimum age of 55 years or a mean age of 55 years, and with valid measurements of cognition before and after ECT.

RESULTS

Nine out of the 15 eligible studies were focused exclusively on the elderly. Three studies reported verbal learning- and recall problems post ECT, while three studies found positive effects of ECT on memory, speed of processing and concentration. Global cognitive functioning in patients with cognitive impairment improved in all studies. At follow up, most studies reported improvement of cognitive functions. Learning verbal information and executive functioning were impaired in M-ECT patients whereas global cognition remained stable after M-ECT over a year.

CONCLUSIONS

To date research of ECT on cognitive functioning in the elderly is very limited. Small sample size, lack of controls, use of a single screening instrument and a short follow up period may explain the conflicting results. Given the clinical importance, more extensive research on cognition in elderly treated with ECT is urgently needed.

The cognitive side effects of modern ECT: patient experience or objective measurement?

This article explores the subjective experience of cognitive deficits of patients who are treated with electroconvulsive therapy, by using actual comments made in clinical situations. The material is divided into 4 themes: the need for clear information, the importance of validation of experience, the impact of daily disruptions, and the issue of self-esteem. It is argued that despite the low correlation which exists between objectively measured cognitive function and the subjectively experienced impairment, the discrepancy creates a need to take both perspectives into consideration rather than to rely on one or the other. The validity and limitations of using personal narrative as a relevant clinical parameter are discussed.

Strategies to minimize cognitive side effects with ECT: aspects of ECT technique

The adverse cognitive effects of electroconvulsive therapy are important limitations in the use of this treatment that continues to be a significant therapeutic strategy after 7 decades of use. Among the approaches to mitigation of these side effects are considerations involving the prescription and manipulation of the electrical stimulus itself. The impact of the following electrical factors on the cognitive outcomes of electroconvulsive therapy are surveyed: efficiency of the stimulus as expressed in electrical waveform; targeting of the stimulus, the major concept underlying electrode placement; stimulus dosing; and frequency and number of treatments. The current state of development of knowledge in these areas is summarized, and methods to achieve the best cognitive outcomes without sacrificing clinical efficacy are discussed. Future trends in the further optimization of the electrical stimulus are briefly mentioned.

Cognitive side effects of brief pulse electroconvulsive therapy: a review

Cognitive impairment remains a common side effect of brief pulse electroconvulsive therapy (ECT), and its minimization has been the motivation for many different treatment modifications over the decades. The level of impairment has been shown to vary according to different technical parameters of ECT including, but not limited to, electrode placement, dosage, and waveform, as well as patient factors, such as age and premorbid intellect. Most past research has focused the assessment on memory impairments associated with ECT. Specifically, ECT can result in both anterograde and retrograde memory impairments. However, the study of non-memory cognitive functions after ECT has been relatively neglected. Furthermore, although considerable recovery has been observed within weeks of treatment completion, data are lacking in the longer term. The following article presents an overview of what is currently known about the pattern and recovery of cognitive side effects of ECT. Controversies within the literature and areas requiring further research are highlighted.

Introduction of vagus nerve stimulation into a maintenance electroconvulsive therapy regimen: a case study and cost analysis

OBJECTIVE

This case report describes the outcome of a patient implanted with the vagus nerve stimulation (VNS) device while receiving maintenance electroconvulsive treatment (M-ECT) and compares the costs of treatment options for treatment-resistant depression.

METHODS

The patient, a male, aged 47 years with bipolar I disorder, treatment-resistant depression, and a 13-year history of depressions, was receiving M-ECT at 2-week intervals as well as antidepressant medications when he was implanted with the VNS device. His depression was assessed with the Montgomery-Asberg Depression Rating Scale. The cost analysis of treatment modalities placed M-ECT at $800 to $1000 per treatment and VNS at approximately $3900 annually (surgery, device, and office visits, approximately $31,300, was prorated over 8 years).

RESULTS

Antidepressants and other medications were used in combination and were gradually changed while the patient was receiving electroconvulsive therapy. The patient improved with VNS and was able to discontinue M-ECT. His Montgomery-Asberg Depression Rating Scale scores had fluctuated between 2 and 56, but, after VNS, the scores decreased to a level consistent with remission and have remained at those levels. The patient reported feeling as well as he had felt at any time he could remember, began an exercise program, and lost 30 lbs. During the 10 months before implantation, 14 electroconvulsive therapy treatments cost $11,200 to $14,000. For 10 months after implantation, 7 M-ECT treatments ($5600-$7000) plus prorated VNS ($3250) equaled $8850 to $10,250, $2350 to $3750 less than before implantation.

CONCLUSIONS

This patient improved with VNS and was able to discontinue M-ECT. Introducing VNS effected a cost savings over M-ECT.

Electroconvulsive therapy: an effective therapy of medication-resistant bipolar disorder

OBJECTIVES

We report our experience with a medication-refractory patient with bipolar I disorder, who remained clinically stable under continuation electroconvulsive therapy (C-ECT). We found ECT to be effective in providing functionality for a patient when various medications had failed.

METHODS AND RESULTS

A 53-year-old woman with a 31-year history of recurrent manic and depressive episodes poorly responsive to medications warranted an ECT trial. Remission was achieved after 12 treatments and C-ECT at weekly intervals was used as maintenance therapy. C-ECT was continued for 37 months and 85 treatments, and discontinued when anesthetic difficulties precluded further treatment. Three months after the last ECT, she was readmitted in a severe manic relapse. Restarting ECT caused rapid remission. There are no signs of cognitive deterioration during C-ECT.

CONCLUSION

Long-term C-ECT is an effective and safe prophylactic treatment in individual treatment-resistant patients with bipolar disorder.

Clinical Outcome and Memory Function With Maintenance Electroconvulsive Therapy

Although maintenance electroconvulsive therapy (ECT) appears to be the logical choice for the prevention of relapses and recurrences in patients with refractory depression who have responded to a course of ECT, the perception of ECT's negative effect on memory continues to limit its wider use. This retrospective study of depressed patients maintained on ECT after an initial course revealed that maintenance ECT was effective in sustaining clinical improvement, particularly in patients who showed a satisfactory clinical response to the initial course of ECT, and that memory difficulties were limited and tolerable.

Erhaltungselektrokrampftherapie bei depressiven Störungen

Nowadays, electroconvulsive therapy (ECT) is undergoing a renaissance in psychiatry: it is now considered a first-line therapy for treating psychotic depression or other disorders with severe depressive symptoms. Surprisingly, ECT is most commonly not used as continuation therapy after acute remission. With rare exceptions, antidepressive medication is chosen for this purpose. The use of continuation ECT (cECT) and subsequent maintenance ECT (mECT) is not or just marginally mentioned in practice guidelines. In this article, we suggest guidelines for cECT, taking therapy recommendations and recent studies into account. Particularly, indication, management, comedication and comorbidity, side effects, and costs are examined. Today, cECT is underindicated as a result of assumed problems, fears, and stigmas. We would therefore recommend broader use of this proven treatment tool for keeping major depression in remission.

Successful maintenance electroconvulsive therapy for more than seven years

We report on a patient with recurrent major depressive episodes with psychotic features who was successfully treated with maintenance electroconvulsive treatment (M-ECT) over a long period without the need for concurrent treatment with an antidepressant or mood stabilizer. She started ECT in 1996 and has received M-ECT for more than 7 years. To date (2005), she has received 244 treatments. After 5 admissions in nearly 4 years, involving 29 months in hospital, she has not needed any further psychiatric admission for 7 1/2 years since the start of the M-ECT. Her depression has been in complete remission for nearly 6 years, with the exception of one mild-to-moderate nonpsychotic depressive episode lasting for 2 months. The patient exhibited slight cognitive deficits but had no subjective complaints before ECT, and her cognitive deficits did not worsen after the initial ECT. Thus M-ECT does not appear to cause cognitive deterioration. M-ECT is being continued on the patient's request.