ECT plus Antidepressants: a Review

Out on PubMed, from researchers in Rotterdam, The Netherlands, is this review:

Influence of an adjuvant antidepressant on the efficacy of electroconvulsive therapy: A systematic review and meta-analysis.

Pluijms EM, Kamperman AM, Hoogendijk WJ, Birkenhäger TK, van den Broek WW.Aust N Z J Psychiatry. 2020 Sep 8:4867420952543. doi: 10.1177/0004867420952543. Online ahead of print.PMID: 32900217
Here is the "Conclusion" section from the text:

Our results suggest that an adjuvant antidepressant enhances the efficacy of ECT in patients with major depression. Although the included studies had some methodological limitations, effect sizes were consistently small to moderate. We speculate that modern-day controlled trials using adequately dosed TCAs and MAOIs will most likely result in larger effect sizes. From a clinical point of view, we prefer an adjuvant TCA to an adjuvant MAOI, since TCAs are generally safe to use with ECT (American Psychiatric Association, 2001Baghai et al., 2006Naguib and Koorn, 2002Sackeim et al., 2009), whereas MAOIs warrant precautions during anaesthesia for ECT (Dolenc et al., 2004Naguib and Koorn, 2002). Moreover, MAOIs are prescribed far less commonly than TCAs and the use of an MAOI requires dietary restrictions.

Thus, if ECT is indicated for a patient with major depression, we recommend the routine use of an adequately dosed adjuvant antidepressant to improve the efficacy of ECT. We leave the choice between a TCA, an SSRI/SNRI and an MAOI up to the clinician. Our findings warrant renewed interest in adjuvant pharmacotherapy during ECT for major depression.

This is a carefully crafted and very useful systematic review and meta-analysis of an important topic. The authors are clear in their belief that, despite the limitations of the literature, concomitant antidepressant (AD) use with ECT is helpful.

Although not mentioned, because there was no placebo group in the acute phase, the PRIDE study added to the evidence base of the safety/tolerability of combined venlafaxine and ECT.

The reluctance of the current generation of psychiatrists to prescribe TCAs and MAOIs, while unfortunate, is likely to continue, despite these findings; it is therefore anticipated that SSRIs/SNRIs will be the class of AD most commonly prescribed with ECT.


  1. Dear Charles,

    As a non believer of benefit of the combination antidepressants and ECT I was also impressed with the results of our review. One of our ideas is that especially irreversible MAO inhibitors could be of benefit during the ECT. Would be exciting to do a placebo controlled trial.
    Thanks for the review on your blog.
    Take care Walter van den Broek

  2. In the 1980s, our ECT service routinely discontinued antidepressants under the presupposition that if the antidepressant did not prevent the need for ECT, then it probably had no value during ECT. While the premise that switching to anew antidepressant during ECT has not been empirically compared against leaving the patient on the old antidepressant, at least we now know there is no pressure to remove antidepressants altogether
    -Vaughn McCall


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