ECT non-remitters: prognosis and treatment after 12 unilateral electroconvulsive therapy sessions for major depression.
J Affect Disord. 2020 Jul 1;272:501-507. doi: 10.1016/j.jad.2020.03.134. Epub 2020 Apr 29.PMID: 32553394
Background: Depressive disorder causes significant suffering in patients and caregivers worldwide. Electroconvulsive therapy (ECT) is a highly effective antidepressant treatment, but little is known about the prognosis and treatment of patients who do not achieve remission with ECT. We investigated prognosis and treatment of patients with major depression who did not achieve remission after 12 unilateral electroconvulsive therapy sessions.
Methods: We conducted a retrospective, naturalistic follow-up study. Patients who had previously participated in a double-blind randomized controlled trial that compared brief pulse with ultra-brief pulse ECT and who had not achieved remission after 12 right unilateral (RUL) ECT sessions were selected for this study. We analysed the type of treatments received during the 6-month follow-up and studied the occurrence of remission and response. The primary outcome was remission, defined as a Montgomery-Åsberg Depression Rating Scale score <10.
Results: Eighty-one patients were randomized, of which 18 patients did not remit. Eight of these non-remitters achieved remission during follow-up (44.4%) while 7 did not achieve remission (38.9%). Remission data could not be retrieved for 3 patients (16.7%). Remission was achieved in 6 patients by a combination of continuing unilateral ECT with antidepressants or switching to bilateral ECT.
Limitations: This is a retrospective study with only a small number of patients. Treatment after RUL ECT non-remission was not standardized.
Conclusion: When patients with major depression do not achieve remission after 12 RUL ECT sessions, they have still a reasonable chance of remission within 6 months. Continuing ECT has the best chance of success.
This is an important study despite its small size and other limitations. It is principally important for focusing attention on the issue of what to do to when patients do not respond adequately to RUL ECT. There is remarkably little data on this. The authors' observed 30% remission rate with switch to BL ECT seems low, and cannot be taken as definitive, due to the very small numbers. Overall, the message here is that with additional ECT and pharmacotherapy manipulations, there is a good chance to achieve remission.
Algorithms for progressing from "weaker" to "stronger" forms of ECT need to be developed by the field. In my opinion, the reification of RUL ECT and the corollary vilification of BT (including BF) is an exaggerated response to the transient tolerability issues with BT. As I have said many times before, to say that the two electrode placements have comparable efficacy is to confuse group data with individual patient-level data. Most of the world's ECT is done with bilateral electrode placement; there is clearly room for different ECT techniques, tailored to the individual needs of the patient, and the urgency of the clinical situation.
The below comment is from Max Fink:
ReplyDeleteQuestions of RUL ECT research
In this follow-up study of RUL UBP and BP treatments, volunteers were subjected to known less effective treatments than were otherwise available. The first tests of RUL and BT ECT done in 1950s, repeated in1970s, and again in 1990s consistently reported that BT ECT was effective in >80% of depressed patients while RUL ECT was effective in <60% of the patients.1 The investigators tested a questionable technical hypothesis, that UBP currents would produce less memory consequences than BP with the same efficacy rate. That hypothesis was disproven, with RUL UBP treatments less effective than RUL BP treatments (and surely less effective than BT ECT). In this follow-up study, the authors find that some study patients were not relieved of their illness by proper follow-up care.
Are volunteers for medical RCT studies owed the ethical protection of continued care if the randomization ends in lesser effective treatment?2
Max Fink
1. Fink M, Taylor MA. Electroconvulsive therapy: Evidence and challenges. JAMA 2007; 298: 330-332.
2. Ottosson J-O, Fink M. Ethics in Electroconvulsive Therapy. NY: Bruner-Routledge, 2004