LOS ANGELES – Data continue to affirm the efficacy of electroconvulsive therapy, or ECT, for the treatment of major depression and other mood disorders, and numerous studies show that the benefits are particularly pronounced in older patients.
ECT experts at the annual meeting of the American Association for Geriatric Psychiatry shared some of these findings, along with newer data on optimal electrode placement, and an emerging indication for electroconvulsive therapy.
CORE age-related findings
Among adults aged 18-85 who were treated with ECT for unipolar depression in one study, for example, older patients responded better than did younger patients, Dr. Georgios Petrides said.
That study, the first from CORE (the Consortium for Research in Electroconvulsive Therapy), compared ECT with combination antidepressant/antipsychotic pharmacotherapy as a strategy for depression relapse prevention in 201 patients who had remitted after a course of bilateral ECT. Patients from five sites were randomized to receive either 10 continuation ECT treatments or 6 months of treatment with lithium and nortriptyline, said Dr. Petrides of the department of psychiatry at the Albert Einstein College of Medicine, New York, and director of ECT research at the Zucker Hillside Hospital, Glen Oaks, N.Y.
Both groups fared better than a historical placebo control group, but did not differ significantly from each other with respect to remission rates; 46% of patients in both groups remained in remission. Also, no differences were seen between the groups with respect to time to relapse among those who did not remain in remission (Arch. Gen. Psychiatry 2006;63:1337-44).
However, a later analysis of CORE data by age (18-45 years; 46-64 years; and 65 years and older) showed that the remission rates were significantly greater – at up to 90% – for the older patients, compared with the youngest group, Dr. Petrides said.
Of note, relapse rates were lower among patients with psychotic depression, compared with those with non-psychotic depression, and the age-based advantage also was apparent among those with psychotic depression, he said.
Age and electrode placement
A more recent CORE study looking at electrode placement for optimal efficacy and minimal cognitive impairment demonstrated age-based differences in outcomes as well.
In a randomized, controlled, double-blind trial, outcomes in 230 patients with major depression and a mean age of nearly 60 years were found to be similar with a novel bifrontal placement using 1.5 times the seizure threshold, a standard bitemporal placement using 1.5 times the seizure threshold, and with standard right unilateral placement using 6 times seizure threshold, Dr. Charles H. Kellner said.
All placements resulted in clinically and statistically significant improvements, with remission rates, based on strict remission criteria, of 61%, 64%, and 55% for the bifrontal, bitemporal, and right unilateral placements, respectively.
Using less strict criteria for response rather than remission, the rates for the three groups were 79%, 82%, and 73%%, respectively, noted Dr. Kellner, professor of psychiatry and director of the division of geriatric psychiatry at Mount Sinai School of Medicine, New York (Br. J. Psychiatry 2010;196:226-34).
A more rapid decline in symptoms was seen with bitemporal placement.
"So the take-home message there, is that if you have an urgently ill patient, either psychiatrically or medically, than bilateral electrode placement should be considered for them," said Dr. Kellner, who also is director of the ECT service at Mount Sinai Hospital.
Also of note, the remission rate was "remarkably greater" with right unilateral electrode placement in those over age 65 years, compared with younger patients (nearly 75% vs. about 40%-50%), and the remission rate was worse for bifrontal placement in those over age 65 years, compared with younger patient (about 45% vs. 65%).
"If this finding is replicated – and we’ve already partially replicated it (in the Prolonging Remission in Depressed Elderly [PRIDE] study)," he said. "This is good news that for geriatric patients, right unilateral ECT, the more benign form of the treatment, may be preferentially effective."
The finding that certain placements are better or worse in certain patients or age groups underscores the need for making all placements available, and choosing the one that is most appropriate for a patient’s individual circumstances, and the finding that all three electrode placements are effective underscores the argument that "ECT in contemporary practice is not a technical issue." He added, explaining that the data are clear about the effects of ECT, and that it is important to "fight to continue to get it accepted as a standard treatment – to move it up on the treatment algorithm so it is not considered a last resort for treatment."