Effectiveness of Maintenance ECT: Interesting New Data From Germany During the COVID Pandemic

Out on PubMed, in Acta Psychiatrica Scandinavica, from clinicians in Germany, is this paper:

Effectiveness of maintenance Electroconvulsive Therapy - Evidence from modifications due to the COVID-19 Pandemic.

Methfessel I, Besse M, Belz M, Zilles-Wegner D.Acta Psychiatr Scand. 2021 May 7. doi: 10.1111/acps.13314. Online ahead of print.PMID: 33960406

The abstract is copied below:

Objective: Continuation and maintenance ECT (c-/m-ECT) are effective in the prevention of relapse and recurrence of both affective and psychotic disorders. However, data are scarce concerning the trajectories of severe mental disorders after the end of c-/m-ECT. This prospective study investigates the clinical outcome of patients with versus without modifications of their c-/m-ECT schedules.

Methods: In the context of the COVID-19 pandemic, ECT capacities were restricted at many clinics in early 2020. All patients receiving c-/m-ECT in March and April 2020 at our department (n = 53, unipolar depression, bipolar disorder, schizophrenia) were followed up for six months to investigate the impact of treatment modifications imposed by the pandemic. Based on individual decisions, c-/m-ECT was either (a) continued without modification, (b) continued with reduced frequency, or (c) discontinued.

Results: Both reduced frequency and discontinuation of c-/m-ECT were associated with significant clinical deterioration as measured by CGI-I (Clinical Global Impression Scale - Global Improvement) during the six-months follow-up when compared to the subgroup of patients without any treatment modification (p = .005, p = .011). Furthermore, patients with discontinued or reduced c-/m-ECT showed significantly higher rates of rehospitalizations (p = .028) and new acute courses of ECT (p = .018).

Conclusion: Despite the limitations of a heterogeneous and relatively small sample, our study strongly corroborates the effectiveness of c-/m-ECT in a real-world population. Especially patients with shorter time since index ECT seem to be at high risk for severe clinical deterioration in the case of treatment discontinuation or reduction.

Keywords: COVID-19; Electroconvulsive Therapy; continuation ECT; effectiveness; maintenance ECT.

And from the text:

In our prospective, naturalistic study, patients with reduced frequency or complete discontinuation of c-/mECT showed a significant clinical deterioration as measured with CGI-I during the six months follow-up in comparison to patients with unchanged c-/m-ECT schedules. In addition, patients with reduced and discontinued treatment showed significantly higher rates of both rehospitalization and new acute ECT series within the first six months after cessation of c-/m-ECT. In total, 27 out of 46 patients (58.7%) who were affected by any change in their c-/m-ECT experienced some kind of clinical deterioration (i.e. CGI-I ≥ 5 and/or rehospitalization and/or new acute ECT). In contrast, only one out of seven patients without treatment modification met one of these criteria. This difference is even more interesting, as the patients without modification of c-/m-ECT had the highest risk for relapse according to our clinical judgement at baseline. 

This paper is a fine addition to the evidence base in the literature for the effectiveness of maintenance ECT. The authors have taken advantage of an "experiment of nature" (the COVID epidemic necessitating drastic curtailment of their ECT program) to collect excellent data on a cohort of 53 patients. Quite simply, taking away maintenance ECT from very vulnerable patients with severe and recurrent illness results in clinical deterioration.

Every bit of data about maintenance ECT is valuable; remember that the US FDA failed to endorse it (mistakenly, I believe) in their 2018 ruling on the reclassification of ECT devices.

This paper is worth a full and careful read, ~15 minutes.