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Pharmacological Strategies in the Prevention of Relapse After Electroconvulsive Therapy

Prudic, Joan MD*; Haskett, Roger F. MD; McCall, W. Vaughn MD; Isenberg, Keith MD§; Cooper, Thomas MA*; Rosenquist, Peter B. MD; Mulsant, Benoit H. MD, FRCPC†∥; Sackeim, Harold A. PhD*

doi: 10.1097/YCT.0b013e31826ea8c4
Original Study

Objective To determine whether starting antidepressant medication at the start of electroconvulsive therapy (ECT) reduces post-ECT relapse and to determine whether continuation pharmacotherapy with nortriptyline (NT) and lithium (Li) differs in efficacy or adverse effects from continuation pharmacotherapy with venlafaxine (VEN) and Li.

Methods During an acute ECT phase, 319 patients were randomized to treatment with moderate dosage bilateral ECT or high-dosage right unilateral ECT. They were also randomized to concurrent treatment with placebo, NT, or VEN. Of 181 patients to meet post-ECT remission criteria, 122 (67.4%) participated in a second continuation pharmacotherapy phase. Patients earlier randomized to NT or VEN continued on the antidepressant, whereas patients earlier randomized to placebo were now randomized to NT or VEN. Lithium was added for all patients who were followed until relapse or 6 months.

Results Starting an antidepressant medication at the beginning of the ECT course did not affect the rate or timing of relapse relative to starting pharmacotherapy after ECT completion. The combination of NT and Li did not differ from VEN and Li in any relapse or adverse effect measure. Older age was strongly associated with lower relapse risk, whereas the type of ECT administered in the acute phase and medication resistance were not predictive. Across sites, 50% of the patients relapsed, 33.6% continued in remission 6 months after ECT, and 16.4% dropped out.

Conclusions Starting an antidepressant medication during ECT does not affect relapse, and there are concerns about administering Li during an acute ECT course. Nortriptyline and VEN were equally effective in prolonging remission, although relapse rates after ECT are substantial despite intensive pharmacology. As opposed to the usual abrupt cessation of ECT, the impact of an ECT taper should be evaluated.

From the *New York State Psychiatric Institute and Department of Psychiatry, Columbia University, New York, NY; †Western Psychiatric Institute andClinic and the Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA; ‡Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; §Department of Psychiatry, Washington University, St. Louis, MO and ∥Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.

Received for publication August 5, 2011; accepted June 27, 2012.

Reprints: Joan Prudic, MD, New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032 (e-mail:

This study was supported in part by grants RO1 MH35636 (Dr Sackeim), RO1 MH61609 (Dr Sackeim), RO1 MH61594 (Dr McCall), RO1 MH61621 (Dr Isenberg), and RO1 MH61591 (Dr Haskett) from the US Public Health Service, Rockville, MD. A grant was obtained from Wyeth Pharmaceuticals for the purchase of the medications used in this study. The ECT devices used were loaned by the MECTA Corporation.

The authors have no conflicts of interest or financial disclosures to report.

© 2013 Lippincott Williams & Wilkins, Inc.