ECT and Treatment Resistance: New Study in Acta Psychiatrica Scandinavica

The impact of treatment resistance on outcome and course of electroconvulsive therapy in major depressive disorder.

Rovers JJE, Vissers P, Loef D, van Waarde JA, Verdijk JPAJ, Broekman BFP, Vergouwen ACM, Oudega ML, van Exel E, Coenen R, Everaerd DS, Tendolkar I, Dols A, van Eijndhoven PFP.Acta Psychiatr Scand. 2023 Mar 30. doi: 10.1111/acps.13550. Online ahead of print.PMID: 3702042


The abstract is copied below:


Introduction: Major depressive disorder (MDD) is a common psychiatric disorder. Despite several treatment options, a subgroup of patients will not respond to the commonly used antidepressant treatments and thus express treatment resistance (TRD). TRD can be quantified with the Dutch Measure for Treatment Resistance in Depression (DM-TRD). Electroconvulsive therapy (ECT) is an effective treatment for MDD, also in TRD. Yet, the position of ECT as "treatment-of-last-resort" may decrease the likelihood of beneficial outcome. Our aim was to investigate the association between treatment resistance and outcome and course of ECT.

Methods: We performed a retrospective, multicenter cohort study with 440 patients of which data was retrieved from patient records as collected in the Dutch ECT Cohort database. Linear and logistic regression models were used to explore the association between level of treatment resistance and outcome of ECT. Median split was used to explore the differences between high and low level of TRD and course of treatment.

Results: A higher DM-TRD score was associated with significantly smaller reduction of depression symptoms (R2 = 0.160; β = -2.968; p < 0.001) and lower chance of response (OR = 0.821 [95 CI: 0.760-0.888]; β = -0.197; p < 0.001). Low level TRD patients underwent fewer ECT sessions (mean 13 ± 6 SD vs. 16 ± 7 SD; p < 0.001) and fewer switches from right unilateral tot bifrontotemporal electrode placement (29% vs. 40%; p = 0.032).

Conclusion: Reserving ECT as "treatment-of-last-resort" in the treatment algorithm for MDD seems questionable, because in our study lower level of treatment resistance predicted more beneficial ECT-outcome. Moreover, providing ECT in less treatment resistant patients showed fewer needed ECT-sessions and less switches to BL electrode placement, which may decrease the risk for cognitive side-effects.
Keywords: ECT; affective disorders; depression; treatment.

The article is here.

And from the text:






This is an excellent paper. The main conclusion, that ECT should be prescribed earlier, is well taken. I am not a big fan of the concept of "treatment resistance," but the authors here do a very good job of showing how relevant it is, using this particular Dutch instrument for measurement. The finding of switch to BL electrode placement in 30-40% of this cohort add data to the discussion of the relative potency of RUL vs BL ECT.

I recommend a full and careful read of this paper ( ~ 15 minutes) to all ECT practitioners.

Kudos to our Dutch colleagues.


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