13. Management of Patient's Post-ECT Course

13.1. Continuation therapy is traditionally defined as the provision of somatic treatment over the 6 month period following, the onset of remission in an index episode of mental illness (National Institute of Mental Health Consensus Development Panel 1985; Prien & Kupfer 1986; Fava & Kaji 1994). However, individuals referred for ECT are particularly likely to be medication resistant and to display psychotic ideation during the index episode of 'illness, and the risk of relapse remains high (50-95%) throughout the first year following completion of the ECT course (Spiker et al. 1985; Aronson et al 1987; Sackeim et al 1990a,b, 1993; Stoudemire et al. 1994; Grunhaus et al. 1995). For this reason, we will operationally define the continuation interval as the 12 month period following successful treatment with ECT.

Regardless of its definition, continuation treatment has become the rule in contemporary psychiatric practice (American Psychiatric Association 1993, 1994, 1997). Following completion of the index ECT course, an aggressive program of continuation therapy should be instituted as soon as possible. Occasional exceptions include patients intolerant to such treatment and possibly those with a history of extremely long periods of remission (although compelling evidence, for the latter is lacking).

13.2. Continuation pharmacotherapy. A course of ECT is usually completed over a 2- to 4-week period. Traditional practice, based in part on earlier studies (Seager and Bird 1962; Imlah et all. 1965; Kay et al. 1970) and in part on clinical experience, has suggested continuation treatment of patients with unipolar depression with antidepressant agents (and possibly antipsychotic agents in the presence of psychotic symptoms), patients with bipolar depression with antidepressant and/or mood stabilizer medications; patients with mania with mood stabilizer and possibly antipsychotic agents, and patients with schizophrenia with antipsychotic medications (Sackeim 1994). However, some recent evidence suggests that a combination of antidepressant and mood stabilizer pharmacotherapy might improve the effectiveness of continuation therapy for patients with unipolar depression (Sackeim 1994). It may also be beneficial to discontinue antidepressant medications during the continuation phase of treatment for patients with bipolar depression (Sachs 1996). For patients with major depression episodes, medication dosages during continuation treatment are maintained at the clinically effective dose range for acute treatment, with adjustment up or down depending upon response (American Psychiatric Association 1993). For patients with bipolar disorder or schizophrenia, a somewhat less aggressive approach is utilized (American Psychiatric Association 1994, 1997). Still, the role of continuation therapy with psychotropic drugs after a course of ECT continues to undergo assessment (Sackeim 1994). In particular, disappointingly high relapse rates, especially in patients with psychotic depression and in those who are medication resistant during the index episode (Sackeim et al. 1990a: Meyers 1992; Shapira et al. 1995; Flint & Rifat 1998), compel reevaluation of present practice, and suggest consideration of novel medication strategies or continuation ECT.

13.3. Continuation ECT. While psychotropic continuation therapy is the prevailing practice, few studies document the efficacy of such use after a course of ECT. Some recent studies report high relapse rates even in patients complying with such regimens (Spiker et al. 1985, Aronson et al. 1987; Sackeim, et al. 1990, 1993); Stoudemire et al. 1994). These high relapse rates have led some practitioners to recommend continuation ECT for selected cases (Decina et al. 1987; Kramer 1987b; Jaffe et al. 1990b; McCall et al. 1992). Recent reviews have tended to report surprisingly low relapse rates among patients so treated (Monroe 1991; Escande et al. 1992; Jarvis et al. 1992; Stephens et al. 1993; Favia & Kaji 1994; Sackeim 1994; Fox 1996; Abrams 1997a; Rabheru & Persad 1997). Continuation ECT has also been described as a viable option in contemporary guidelines for long-term management of patients with major depression (American Psychiatric Association 1993), bipolar disorder (American Psychiatric Association 1994), and schizophrenia (American Psychiatric Association 1997).

Recent data on continuation ECT have primarily consisted of retrospective series in patients with major depression (Decina et al. 1987; Loo et al. 1988; Matzen et al. 1988; Clarke et al. 1989; Ezion et al. 1990; Grunhaus et al. 1990; Kramer 1990; Thienhaus et al. 1990; Thornton et al. 1990; Dubin et al. 1992; Puri et al. 1992; Petrides et al. 1994; Vanelle et al. 1994; Swartz et al. 1995; Beale et al. 1996), mania (Abrams 1990; Kellner et al. 1990; Jaffe et al. 1991; Husain et al. 1993; Vanelle et al. 1994; Godemann & Hellweg 1997), schizophrenia (Sajatovik & Neltzer 1993; Lohr et al. 1994; Hoflich et al. 1995; Ucok & Ucok 1996; Chanpattaria 1998), and Parkinson's Disease (Zervas & Fink 1991; Friedman & Gordon 1992; Jeanneau 1993; Hoflich et al. 1995; Aarsland et al. 1997; Wengel et al. 1998). While some of these investigations have included comparison groups not receiving continuation ECT or have compared use of mental health resources before and after implementation of continuation ECT, controlled studies involving random assignment are not vet available. Still, suggestive evidence that continuation ECT is cost-effective, in spite of the cost per treatment, is particularly promising (Vanelle et al. 1994; Schwartz et al. 1995; Steffens et al. 1995; Bonds et al. 1998). In addition, an NIMH-funded, prospective multi-site study comparing continuation ECT with continuation pharmacotherapy with the combination of nortriptyline and lithium is presently underway (Kellner - personal communication).

Because continuation ECT appears to represent a viable form of continuation management of patients following completion of a successful course of ECT, facilities should offer this modality as a treatment option. Patients referred for continuation ECT should meet the following indications: 1) history of illness that is responsive to ECT; 2) either resistance or intolerance to pharmacotherapy alone or a patient preference for continuation ECT; and 3) the ability and willingness of the patient to receive continuation ECT, provide informed consent, and comply with the overall treatment plan, including the behavioral restrictions that may be necessary.