Meds for Relapse Prevention After ECT: Data From Four Academic Medical Centers
Out on PubMed, from researchers "on behalf of" the STOP-PD II Study Group in the USA and Canada, is this dataset:
Pharmacotherapy Prescriptions for Relapse Prevention of Psychotic Depression After Electroconvulsive Therapy.
J Clin Psychopharmacol. 2021 Feb 11. doi: 10.1097/JCP.0000000000001354. Online ahead of print.PMID: 33587400
The abstract is copied below:
Purpose/background: Electroconvulsive therapy (ECT) is effective in the treatment of acute episodes of psychotic depression. However, no adequately powered studies have directly investigated the efficacy of antipsychotic pharmacotherapy in relapse prevention of psychotic depression after ECT. In the absence of such literature, we reviewed the clinical practice of 4 academic medical centers that have made research contributions in the treatment of psychotic depression over the past 20 years.
Methods/procedures: We reviewed medical records of patients with a diagnosis of psychotic depression who received 1 or more acute courses of ECT over the span of 3 years. Chi-square tests were used to compare pharmacotherapy prescribed at the time of completion of ECT.
Findings/results: A total of 163 patients received 176 courses of ECT for separate episodes of psychotic depression. The combination of an antidepressant plus an antipsychotic was the most common regimen, ranging from 61.9% to 85.5% of all prescriptions. One center added lithium in 45.5% of cases treated with the combination of an antidepressant plus an antipsychotic. An antipsychotic alone was prescribed in less than 10% of cases. An antidepressant alone or other drug combinations were rare.
Implications/conclusions: The combination of an antidepressant plus an antipsychotic was the most commonly prescribed regimen at the completion of ECT for relapse prevention in patients with psychotic depression acutely treated with ECT. Although this report offers a view of the clinical practice of 4 academic medical centers, it also points to the need of randomized controlled trials on continuation pharmacotherapy after treatment of psychotic depression with ECT.
and from the text:
Psychotic depression is difficult to treat, and even when it remits, it has a high relapse rate. Naturalistic treatment studies report relapse rates from 11.3% to 45% at 6 months and as high as 86.5% at 2 years.1–4 The period of greatest risk for relapse is within the first 3 months of discontinuation of a treatment associated with remission, particularly discontinuation of antipsychotic medication....The most recent American Psychiatric Association Practice Guidelines recommend either the combination of an antidepressant and an antipsychotic drug or electroconvulsive therapy (ECT) for the treatment of an acute episode of psychotic depression.12 In a randomized controlled trial (RCT), the combination of olanzapine plus sertraline was associated with a remission rate of 41.9%, whereas the remission rate of the olanzapine plus placebo arm was 23.9%.6,13 Electroconvulsive therapy is a highly effective treatment for an acute episode of psychotic depression, with 1 open-label study reporting a remission rate of 95% in persons with psychotic depression who completed the course of treatment.14 However, remission of the acute episode of psychotic depression after ECT is followed by a poor postremission clinical course, with up to 50% of patients having a relapse within 12 months and many requiring hospitalization.1,5,15,16 More than 50% of elderly patients with psychotic depression who achieved remission after ECT had relapses or recurrences during 2 years of antidepressant maintenance.
and a Table:
This study is a chart review of prescribed post-ECT pharmacotherapy from four academic medical centers. It reveals sophisticated practice that may, or may not be, generalizable to broader practice patterns. The authors note variability of adding lithium to medication combinations; lithium is likely even less used in community practice. They note that their data are from medical records only, and do not reflect any knowledge of medication adherence. Clearly, the message here is that aggressive post-ECT continuation treatment should be the standard of care.
The brief review of the post-ECT relapse literature has the sense of damning with faint praise, unfortunately feeding into the misleading trope of "short-term only" benefit.
The main points of the paper are all well summarized in the abstract and text excerpts above.
Comments
Post a Comment