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Friday, July 4, 2008

Psychotic Depression, ECT and Continuation Treatment in the Elderly

depressed elderly
After remission on ECT for psychotic depression the combination of nortriptyline and ECT prevented relapse or recurrence in 11 of 16 patients during follow-up of 2 years, of the 17 nortriptyline treated patients only 5 were considered without relapse or recurrence. The mean survival time until relapse was 23 months in the ECT with nortriptyline group and 16 months in the nortriptyline group.

ECT or electroshock is the only treatment in psychiatry that is stopped when successful. Usually treatment is continued with an antidepressant or the combination of an antidepressant with lithium. Tricyclic antidepressants are mostly used because most research on continuation treatment after ECT is done with these antidepressants.

Most research is done with adults not specifically with elderly. When a severely depressed elderly is admitted to our ward and recovers I usually advice them not to stop their antidepressants. I have seen to many relapse when tapering or stopping their antidepressants. There time left is to valuable to spent on psychiatric wards.

A severe form of depression, psychotic depression usually warrants ECT treatment in the elderly. This severe form of depression leads to deterioration fast which can be interrupted effectively by ECT.

In this research a group of elderly with psychotic depression was treated with ECT and nortrityline. When remitted (33/38, 86.8%) they were randomized single blind to continuation ECT with nortriptyline or nortriptyline alone. The high percentage of remitters is no exception with ECT for psychotic depression.

The combination of continuation ECT with nortriptyline is exceptional. In adults a recent trial comparing continuation ECT to nortriptyline with lithium showed no significant difference in relapse during a 6 month follow-up. You can read about this study published in the Archives of General Psychiatry in a post on this blog. Nevertheless both treatments were well tolerated although cognitive side effects were not adequately monitored.

Other limitations of this study are the small sample size, only 14 had initially received pharmacotherapy for their episode before ECT.
Navarro, V. (2008). Continuation/Maintenance Treatment with Nortriptyline Versus Combined
Nortriptyline and ECT in Late-Life
Psychotic Depression: A Two-Year Randomized Study. American Journal of Geriatric Psychiatry, 16(6), 498-505.


Anonymous said...

Hey Dr. Shock,

Is there a reason that most research is done with tricyclic antidepressants on continuation ECT rather than the newer ones? And is continuation ECT different from maintanance ECT?

I'm just curious! I had ECT a month ago, 5 treatmts., and am fascinated with learning about it. I begin again Monday for another series; I guess I quit too soon!

Anyway, I enjoy your blog.

Dr. Shock said...

Yes, tricyclic antidepressants are used in most studies about continuation treatment after ECT. SSRIs haven't been studied at all after ECT. TCA's are believed to be more appropriate with severe depression.

The difference between continuation treatment and maintenance treatment is arbitrary but continuation treatment is to prevent relapse and maintenance treatment is to prevent recurrence. The continuation phase is 6 months and maintenance treatment after 6 months.
Regards Dr Shock

Mary said...

I had 10 treatments, and I would never ever do it again. It didn't help me at all, only gave me memory loss...Mary