Relapse Following Successful Electroconvulsive Therapy for Major Depression: A Meta-Analysis

Abstract

High rates of early relapse following electroconvulsive therapy (ECT) are typically reported in the literature. Current treatment guidelines offer little information to clinicians on the optimal nature of maintenance therapy following ECT. The aim of this study was to provide a systematic overview of the existing evidence regarding post-ECT relapse. A keyword search of electronic databases was performed for studies appearing in the peer-reviewed literature before January 2013 reporting on relapse rates in responders to an acute course of ECT administered for a major depressive episode. Meta-analyses were performed where appropriate. Thirty-two studies with up to 2 years' duration of follow-up were included. In modern era studies of continuation pharmacotherapy, 51.1% (95% CI ¼ 44.7-57.4%) of patients relapsed by 12 months following successful initial treatment with ECT, with the majority (37.7%, 95% CI ¼ 30.7-45.2%) relapsing within the first 6 months. The 6-month relapse rate was similar in patients treated with continuation ECT (37.2%, 95% CI ¼ 23.4-53.5%). In randomized controlled trials, antidepressant medication halved the risk of relapse compared with placebo in the first 6 months (risk ratio ¼ 0.49, 95% CI ¼ 0.39-0.62, po0.0001, number needed to treat ¼ 3.3). Despite continuation therapy, the risk of relapse within the first year following ECT is substantial, with the period of greatest risk being the first 6 months. The largest evidence base for efficacy in post-ECT relapse prevention exists for tricyclic antidepressants. Published evidence is limited or non-existent for commonly used newer antidepressants or popular augmentation strategies. Maintenance of well-being following successful ECT needs to be improved.

Bitemporal Versus High-Dose Unilateral Twice-Weekly Electroconvulsive Therapy for Depression (EFFECT-Dep): A Pragmatic, Randomized, Non-Inferiority Trial

“…However, the overall remission rate (44.2%) was lower than the rate in some trials (range: 46%265%) (8, 9, 11-13) but similar to that in a large community study (46.7%) (33), while the overall 6-month relapse rate (31.1%) was at the lower limit reported in a recent meta-analysis of post-ECT relapse (26). These differences most likely reflect the pragmatic nature of our trial, in which the number of treatments was decided by the patients and referring physicians rather than by the protocol, as well as a naturalistic follow-up, and are unlikely to be related to concomitant use of antidepressants, which may improve ECT efficacy (12).…”

Neurostimulation as an intervention for treatment resistant depression: From research on mechanisms towards targeted neurocognitive strategies

“…ECT revealed to be a possible alternative for pharmaco-resistant patients, but during the course of such treatment general anesthetics have to be administrated multiple times, and in particular bi-temporal ECT may cause memory and learning impairments (Rami-Gonzalez et al, 2001). Although ECT has proven efficacy at the short term, based on a meta-analysis, it has been shown that despite continuation therapy with pharmacotherapy, the risk of relapse within the first year following ECT is substantial (> 50%), with the greatest risk for relapse within the first 6 months (>37%) (Jelovac, Kolshus, & McLoughlin, 2013).…”

Electroconvulsive Therapy in the Treatment of Mood Disorders: One-Year Follow-up

“…Even with continuation pharmacotherapy and/or the continuation of ECT, the relapse rate was reported to be between 40% and 50% within six months (17,21,22). In a meta-analysis, almost half of the patients relapsed in the first year of maintenance therapy and the majority relapsed in the first six months (23). Continuation pharmacotherapy was found to be more effective than a placebo in that study.…”