Continuation/Maintenance Treatment with Nortriptyline Versus Combined Nortriptyline and ECT in Late-Life Psychotic Depression: A Two-Year Randomized Study

doi:10.1097/JGP.0b013e318170a6fa

The American Journal of Geriatric Psychiatry

Volume 16, Issue 6, June 2008, Pages 498-505

https://doi.org/10.1097/JGP.0b013e318170a6fa Get rights and content

Objective

The identification of effective continuation and maintenance strategies for elderly patients with psychotic depression is a critical issue that has not been fully explored. The aim of this study was to assess the tolerability and efficacy of continuation/maintenance electroconvulsive therapy (ECT) in elderly patients with psychotic depression after acute ECT remission.

Methods

The authors used a longitudinal, randomized, single-blind design to compare by survival analysis the 2-year outcome of two subgroups of elderly patients with psychotic unipolar depression who were ECT (plus nortriptyline) remitters. One group was treated with a continuation/maintenance nortriptyline regimen (N = 17) and the other with combined continuation/maintenance ECT plus nortriptyline (N = 16).

Results

Over 2 years of treatment in elderly, psychotic, unipolar depressed ECT (plus nortriptyline) remitters, the mean survival time was significantly longer in the combined ECT plus nortriptyline subgroup than in the nortriptyline subgroup. No differences were observed between treatments with regard to tolerability.

Conclusions

This study supports the judicious use of combined continuation/maintenance ECT and antidepressant treatment in elderly patients with psychotic unipolar depression who are ECT remitters.

Section snippets

Study Design

The study was conducted at the Hospital Clínic of Barcelona, Spain. It involved a longitudinal, randomized, single-blind trial performed from 2004 to 2007. The trial consisted of two distinct phases: the acute treatment phase, in which elderly patients with psychotic depression received bilateral ECT 3 times per week until they met remission criteria; and a follow-up phase, in which patients who had remitted were randomized 1:1 to either a CM-nortriptyline regime or a combined CM-ECT plus

Sample Description

Figure 1 describes patient disposition. Thirty-eight elderly patients with psychotic depression were included in the acute treatment phase, and then treated with acute ECT (plus nortriptyline). Of these patients, 33 (86.8%) were considered remitters, and were thus admitted into the randomized continuation/maintenance treatment protocol. Of these 33 patients, 17 were then assigned to the CM-nortriptyline group and 16 to the combined CM-ECT plus nortriptyline group. A summary of the baseline and

DISCUSSION

We confirmed our hypothesis about the efficacy of CM-ECT in late-life psychotic unipolar depression. Over 2 years of treatment in ECT remitter, late-life, psychotic, unipolar depressed patients, the mean survival time was significantly longer in the combined ECT plus nortriptyline subgroup than in the nortriptyline subgroup. Specifically, the risk of relapse/recurrence was eightfold higher during the first year of follow-up in the patient subgroup treated without CM-ECT. One minor finding was

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Cited by (76)

Long-term Outcome Following Electroconvulsive Therapy for Late-Life Depression: Five-Year Follow-up Data From the MODECT Study
2022, American Journal of Geriatric Psychiatry
Electroconvulsive therapy (ECT) is the most effective treatment for late-life depression (LLD). Research addressing long-term outcome following an acute course of ECT for LLD is limited. We aimed to describe relapse, cognitive impairment and survival 5 years after a treatment with ECT for severe LLD, and assess the association of clinical characteristics with all three outcome measures.
This cohort study was part of the Mood Disorders in Elderly treated with ECT (MODECT) study, which included patients aged 55 years and older with major depressive disorder. Data regarding clinical course, cognitive impairment and mortality were collected 5 years after the index ECT course. We used multivariable Cox proportional hazards models and logistic regression models to assess the association of clinical characteristics with relapse and survival, and cognitive impairment, respectively.
We studied 110 patients with a mean age of 72.9 years. 67.1% of patients who showed response at the end of the index ECT course relapsed, and the included clinical characteristics were not significantly associated with the risk of relapse. 38.8% of patients with available data showed cognitive impairment at five-year follow-up. 27.5% were deceased; higher age and a higher number of previous psychiatric admissions were significantly associated with increased risk of mortality.
Five-year outcome after a course of ECT for severe LLD seems to be in line with long-term outcome following other acute treatments for severe LLD in terms of relapse, cognitive impairment and survival. Additional studies aimed at improving long-term outcome in severe LLD are warranted.
Guidelines for the management of psychosis in the context of mood disorders
2022, Schizophrenia Research
Psychotic episodes occur in a substantial proportion of patients suffering from major mood disorders (both unipolar and bipolar) at some point in their lives. The nature of these episodes is less well understood than the more common, non-psychotic periods of illness and hence their management is also less sophisticated. This is a concern because the risk of suicide is particularly high in this subtype of mood disorder and comorbidity is far more common. In some cases psychotic symptoms may be signs of a comorbid illness but the relationship of psychotic mood to other forms of psychosis and in particular its interactions with schizophrenia is poorly understood. Therefore, our targeted review draws upon extant research and our combined experience to provide clinical context and a framework for the management of these disorders in real-world practice – taking into consideration both biological and psychological interventions.
Maintenance ECT is associated with sustained improvement in depression symptoms without adverse cognitive effects in a retrospective cohort of 100 patients each receiving 50 or more ECT treatments
2020, Journal of Affective Disorders
: Electroconvulsive therapy (ECT) is the most effective acute treatment for depression, but relapse is common following discontinuation. One strategy for prolonging remission is the use of maintenance ECT, but the clinical evidence supporting its efficacy and safety are limited. We examined the effects of maintenance ECT on depression and cognition.
: Participants were from a retrospective cohort of 100 patients receiving ECT at a freestanding psychiatric hospital and who received at least 50 treatments during a single treatment series. QIDS, BASIS-24, and MoCA were assessed at baseline and every 10 treatments thereafter during the clinical course.
: ECT was associated with a rapid decrease in depression symptoms and overall self-reported mental health status within the first 10 treatments, which was sustained throughout a median of 22.1 months of follow-up. There was no change in cognitive functioning as measured by the MoCA. Bilateral and brief pulse treatment parameters were more common by treatment 50 than at the first treatment. Most participants either continued in ECT at the end of the study period or discontinued due to sustained remission.
: retrospective observational study without control group who did not receive ECT.
: In this ECT cohort with at least 50 treatments, improvement in depression was sustained on QIDS and BASIS-24 and adverse cognitive effects were not detected by serial MoCAs, supporting the utility of maintenance ECT in this cohort.
Outcomes in patients with and without capacity in electroconvulsive therapy
2020, Journal of Affective Disorders
: Electroconvulsive therapy (ECT) is an effective treatment for severe mental illness but access is limited for patients lacking consent capacity. We aimed to compare the symptomatic, cognitive, quality of life (QOL) and functional outcomes of patients with and without capacity receiving ECT for schizophrenia, depression or mania.
: Patients prescribed ECT in a single center had their clinical outcomes pre and post ECT compared with repeated measures ANOVAs. Differences in demographic, clinical characteristics and ECT treatment between the group lacking and having capacity were examined using independent t-tests for continuous variables and chi-squared tests for categorical variables.
: 75.1% of 175 patients lacked capacity. The group lacking capacity had overall poorer cognitive and global functioning pre ECT but higher QOL. Objective psychiatric symptom ratings after ECT improved similarly between groups. Mood, cognition, QOL and function improved in both groups, with more improvement in mood and function in the group lacking capacity and a trend towards greater cognitive improvement (p = 0.051).
: Subgroup analysis by diagnosis was not done due to smaller sample sizes in each group. Cognition was assessed with a general screening instrument not a full neuropsychological assessment.
: ECT is a safe and effective treatment for schizophrenia, bipolar mania and depression, and may provide similar or greater benefits in patients lacking capacity to consent, compared to those with capacity. These results support the provision of a framework for substitute decision making in the patients’ best interests for ECT in patients unable to provide their own consent.
Clinical outcome of maintenance electroconvulsive therapy in comorbid Posttraumatic Stress Disorder and major depressive disorder
2018, Journal of Psychiatric Research
Citation Excerpt :
The rate of suicide in major depression is between 5 and 15% in the outpatient setting, and increased to 15–20% in the inpatient setting, especially in those with comorbid PTSD (Bostwick and Pankratz, 2000; Rihmer et al., 2009). Prior studies indicated a significant lower recurrence rate of severe mental disorders with mECT (11–33%) compared to those with an index course of ECT or antidepressant therapy alone (50–70%) (Martinez-Amoros et al., 2012; Navarro et al., 2008; Russell et al., 2003). Gupta et al. compared clinical outcome of 19 patients with MDD on mECT and 19 patients with MD on antidepressant therapy and reported a reduced rate of psychiatry hospitalization and a decrease in length of hospital stay in the mECT group (Gupta et al., 2008).
Post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) are prevalent and frequently comorbid. Approximately 42–48% of patients with PTSD also meet diagnostic criteria for MDD. Maintenance electroconvulsive therapy (mECT) has been found to be efficacious for the prevention of recurrence of MDD. This study investigated the efficacy of mECT in the treatment of MDD with and without comorbid syndromal PTSD.
This retrospective study includes 36 patients, 26 with MDD and 10 with comorbid MDD & PTSD receiving monthly mECT for a mean of 1.5 years. The mean age was 52 ± 14 years and 25% were female. The change in PTSD and MDD symptoms in response to mECT was assessed using Clinical Global Impression - Severity Scale (CGI-S). Heart rate variability (HRV), 12-month hospitalization rate, suicide rate and all-cause mortality in response to mECT were assessed and compared between groups using repeated generalized linear regression (GLM) analysis.
At mECT baseline, there were no statistically significant differences in CGI-S scores, HRV between patients with MDD alone and those with comorbid MDD and PTSD (P > 0.05). After 12-months of mECT, a significant increase in HRV (mean difference: 10.9 95%CI 4.8–20.3, p = 0.001) and decrease in CGI-S overall (mean difference: 3.5, 95% CI 3.3–3.6, p = 0.001)], PTSD (mean difference: 3.4, 95% CI 3.2–3.6, p = 0.001)], and MDD (mean difference: 3.8, 95% CI 3.5–3.9, p = 0.001)] symptoms in both groups were noted (p < 0.05). No psychiatric hospitalization or suicide occurred in any of the patients.
Maintenance ECT is associated with improved HRV, reduction of both major depression and PTSD symptoms, and a favorable clinical outcome.
Protocolization as a method of addressing heterogeneity in electroconvulsive therapy delivery
2020, Personalized Medicine in Psychiatry
Citation Excerpt :
There is growing evidence for M-ECT, with recent studies showing favorable clinical outcomes of M-ECT in MDD [59,60] and schizophrenia [61,62]. Some studies show that long-term maintenance has been shown to delay relapse into a depressive episode [63–65] and has led to significant decreases in hospitalization and resource utilization in chronically ill patients [66–68]. Symptomatic improvement in ECT-naïve patients may be slower given the preference of UB RUL over BT ECT [37].
Electroconvulsive therapy (ECT) has proven efficacy in the treatment of multiple psychiatric disorders, and there is growing evidence for its use as a maintenance treatment. However, there is substantial heterogeneity in ECT administration with respect to treatment parameters plus frequency of continuation and maintenance therapy. This renders confusion to clinicians seeking best practice guidelines as well as patients who transfer between institutions with different ECT practices. Protocolization is a potential method to address these discrepancies leading to more homogeneous treatment and a narrower standard of care. An ECT treatment protocol influenced by contemporary evidence and guidelines is presented. Strengths and weaknesses of the protocol are discussed.

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Regular Research ArticlesContinuation/Maintenance Treatment with Nortriptyline Versus Combined Nortriptyline and ECT in Late-Life Psychotic Depression: A Two-Year Randomized Study

Objective

Methods

Results

Conclusions

Section snippets

Study Design

Sample Description

DISCUSSION

Am J Geriatr Psychiatry

Am J Geriatr Psychiatry

Med Clin

Am J Geriatr Psychiatry

Psychotic major depression: a benefit-risk assessment of treatment options

Drug Saf

Two-year outcome of psychotic depression in late life

Am J Psychiatry

Efficacy of continuation ECT and antidepressant drugs compared to long-term antidepressants alone in depressed patients

Am J Psychiatry

Continuation and maintenance ECT: a review of recent research

J ECT

Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression. A multisite study from the consortium for research in electroconvulsive therapy (CORE)

Arch Gen Psychiatry

Diagnostic and Statistical Manual of Mental Disorders

A rating scale for depression

J Neurol Neurosurg Psychiatry

Regular Research Articles
Continuation/Maintenance Treatment with Nortriptyline Versus Combined Nortriptyline and ECT in Late-Life Psychotic Depression: A Two-Year Randomized Study