Continuation Pharmacotherapy in the Prevention of Relapse Following Electroconvulsive Therapy

TLDR

ECT is highly effective for major depression but relapse rates are high after discontinuation. The study aimed to evaluate whether continuation therapy with nortriptyline alone or combined with lithium could prevent relapse after ECT. A 24‑week, randomized, double‑blind, placebo‑controlled trial enrolled 84 remitted patients who were assigned to placebo, nortriptyline, or nortriptyline plus lithium. The nortriptyline‑lithium combination lowered relapse to 39% versus 60% with nortriptyline and 84% with placebo, yet relapse remained high, especially within the first month.

Abstract

ContextElectroconvulsive therapy (ECT) is highly effective for treatment of major depression, but naturalistic studies show a high rate of relapse after discontinuation of ECT.ObjectiveTo determine the efficacy of continuation pharmacotherapy with nortriptyline hydrochloride or combination nortriptyline and lithium carbonate in preventing post-ECT relapse.DesignRandomized, double-blind, placebo-controlled trial conducted from 1993 to 1998, stratified by medication resistance or presence of psychotic depression in the index episode.SettingTwo university-based hospitals and 1 private psychiatric hospital.PatientsOf 290 patients with unipolar major depression recruited through clinical referral who completed an open ECT treatment phase, 159 patients met remitter criteria; 84 remitting patients were eligible and agreed to participate in the continuation study.InterventionsPatients were randomly assigned to receive continuation treatment for 24 weeks with placebo (n = 29), nortriptyline (target steady-state level, 75-125 ng/mL) (n = 27), or combination nortriptyline and lithium (target steady-state level, 0.5-0.9 mEq/L) (n = 28).Main Outcome MeasureRelapse of major depressive episode, compared among the 3 continuation groups.ResultsNortriptyline-lithium combination therapy had a marked advantage in time to relapse, superior to both placebo and nortriptyline alone. Over the 24-week trial, the relapse rate for placebo was 84% (95% confidence interval [CI], 70%-99%); for nortriptyline, 60% (95% CI, 41%-79%); and for nortriptyline-lithium, 39% (95% CI, 19%-59%). All but 1 instance of relapse with nortriptyline-lithium occurred within 5 weeks of ECT termination, while relapse continued throughout treatment with placebo or nortriptyline alone. Medication-resistant patients, female patients, and those with more severe depressive symptoms following ECT had more rapid relapse.ConclusionsOur study indicates that without active treatment, virtually all remitted patients relapse within 6 months of stopping ECT. Monotherapy with nortriptyline has limited efficacy. The combination of nortriptyline and lithium is more effective, but the relapse rate is still high, particularly during the first month of continuation therapy.