Classics in ECT-Max Fink's Review of the CORE Studies

What was learned: studies by the consortium for research in ECT (CORE) 1997-2011.

Fink M.Acta Psychiatr Scand. 2014 Jun;129(6):417-26. doi: 10.1111/acps.12251. Epub 2014 Feb 12.PMID: 24571807 
The abstract is copied below:

Objective: To review the findings of the four-hospital collaborative studies of electroconvulsive therapy (ECT) in unipolar depressed patients known as CORE between 1997 and 2011. Unipolar depressed patients were treated with bilateral ECT, and on remission were randomly assigned to a fixed schedule continuation ECT or to combined lithium and nortriptyline for 6 months. A second study compared three electrode placements in unipolar and bipolar depressed patients.

Method: Nineteen published reports were reviewed. The findings are compared with those of a parallel multi-hospital study of ECT led by a Columbia University Collaboration (CUC) team that studied right unilateral ECT in a similar population with similar inclusion/exclusion and remission criteria. Successful ECT was followed by placebo, nortriptyline alone, or combined lithium, and nortriptyline.

Results: Relapse rates after remission were similar with fixed schedule ECT as with medications. Predictors of outcome (psychosis, suicide risk, polarity, melancholia, atypical depression, age) and technical aspects (electrode placement, seizure threshold, speed of response) are discussed,

Conclusion: The findings offer criteria to optimize the selection of patients, the technique, and outcome of ECT for unipolar and bipolar depressed patients. Continuation ECT is an effective alternative to continuation treatment with lithium and nortriptyline. Bilateral electrode placement is more efficient than alternative placements. ECT relieves both bipolar and unipolar depression.

Keywords: atypical depression; bipolar depression; continuation ECT; continuation medication; electroconvulsive therapy; electrode placement; melancholia; outcome predictors: age; psychosis; suicide; unipolar depression.

The pdf is here.

In this classic paper, Dr. Fink gives a brief history of ECT, then a detailed description of the CORE and Columbia University ECT studies. He makes many important points, including that ECT is equally effective for bipolar depression ("non-referral for BP depression is not valid") and that suicidality is quickly relieved by ECT. He strongly endorses bilateral electrode placement and expresses skepticism for the value of dose titration:
"The ST [seizure threshold) is a measure of little heuristic value; it is not clinically justified."
Dr. Fink's trenchant analysis makes this paper an important contribution to the literature, definitely worth a full and careful read (about 20 minutes).

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