Electroconvulsive Therapy: Continuation/Maintenance Therapy

Continuation/Maintenance Pharmacotherapy
For the most part, individuals referred for ECT have disorders that are associated with a high risk of recurrence, particularly during the first 6 months after remission (American Psychiatric Association 1993, 1994b, 1997; American Psychiatric Association Committee on ECT 2000). This phenomenon has been particularly well studied in major depression, for which the 1-year recurrence rate has been estimated to be about 50% or more (Sackeim 1994; Sackeim et al. 1990). For this reason, it is important to provide somatic continuation therapy (American Psychiatric Association Committee on ECT 2000). In most cases, psychotropic agents are used for this purpose. However, given evidence that patients who were medication-resistant during the index episode are particularly unlikely to maintain remission while undergoing continuation pharmacotherapy (Sackeim et al. 1990), the clinician treating a medication-resistant patient who responds to ECT should consider, with the patient, one of two options: 1) giving the patient a different type or class of medication after ECT than had previously been used (for patients with major depression, the clinician should consider using agents from more than one medication class), or 2) considering the use of continuation ECT (see subsection below) (American Psychiatric Association Committee on ECT 2000; Sackeim 1994). Patients with a history of relatively frequent illness recurrences should be given prophylactic medication for a longer period (maintenance therapy).

Continuation/Maintenance ECT
In recent years there has been a resurgence of interest in the use of ECT for prophylactic purposes (Petrides 1998; Rabheru and Persad 1997), possibly because of the failure of pharmacological C/M ECT in many cases.

Typical scheduling of continuation ECT involves gradually shifting from frequent (e.g., weekly) to monthly treatments over a period of 1-3 months, then maintaining the monthly administration schedule up to at least 6 months after remission (or longer if maintenance ECT is indicated) (American Psychiatric Association Committee on ECT 2000; Fink et al. 1996). Decisions regarding scheduling should be made on an ongoing basis, based on the patient’s history and his or her present response. Cautious use of concomitant psychotropic agents should be considered for patients who are unable to be managed with continuation ECT alone. Although continuation ECT may slow down the process of recovering the memory loss caused by the index course, it is believed that the development or worsening of memory impairment is unlikely with monthly treatments. Although there is no “lifetime maximum” number of treatments with ECT, the need for continued ECT should be reviewed by the practitioner and patient at least twice a year, consent should be reobtained at least every 6 months, and anesthetic/medical and cognitive reevaluation should be performed at regular intervals. For patients requiring relatively frequent C/M ECT (i.e., weekly to biweekly) over a period of months to years, the presence of persistent deficits should be weighed against the anticipated benefits of continuing the treatments.