title: Pharmacological strategies in the prevention of relapse after electroconvulsive therapy.
abstract: OBJECTIVE
  To determine whether starting antidepressant medication at the start of electroconvulsive therapy (ECT) reduces post-ECT relapse and to determine whether continuation pharmacotherapy with nortriptyline (NT) and lithium (Li) differs in efficacy or adverse effects from continuation pharmacotherapy with venlafaxine (VEN) and Li.
  
  
  METHODS
  During an acute ECT phase, 319 patients were randomized to treatment with moderate dosage bilateral ECT or high-dosage right unilateral ECT. They were also randomized to concurrent treatment with placebo, NT, or VEN. Of 181 patients to meet post-ECT remission criteria, 122 (67.4%) participated in a second continuation pharmacotherapy phase. Patients earlier randomized to NT or VEN continued on the antidepressant, whereas patients earlier randomized to placebo were now randomized to NT or VEN. Lithium was added for all patients who were followed until relapse or 6 months.
  
  
  RESULTS
  Starting an antidepressant medication at the beginning of the ECT course did not affect the rate or timing of relapse relative to starting pharmacotherapy after ECT completion. The combination of NT and Li did not differ from VEN and Li in any relapse or adverse effect measure. Older age was strongly associated with lower relapse risk, whereas the type of ECT administered in the acute phase and medication resistance were not predictive. Across sites, 50% of the patients relapsed, 33.6% continued in remission 6 months after ECT, and 16.4% dropped out.
  
  
  CONCLUSIONS
  Starting an antidepressant medication during ECT does not affect relapse, and there are concerns about administering Li during an acute ECT course. Nortriptyline and VEN were equally effective in prolonging remission, although relapse rates after ECT are substantial despite intensive pharmacology. As opposed to the usual abrupt cessation of ECT, the impact of an ECT taper should be evaluated.
authors.affiliation: New York State Psychiatric Institute and Department of Psychiatry, Columbia University, New York, NY 10032, USA. jp33@columbia.edu
authors.forename: Joan
authors.initials: J
authors.lastname: Prudic
authors.forename: Roger F
authors.initials: RF
authors.lastname: Haskett
authors.forename: W Vaughn
authors.initials: WV
authors.lastname: McCall
authors.forename: Keith
authors.initials: K
authors.lastname: Isenberg
authors.forename: Thomas
authors.initials: T
authors.lastname: Cooper
authors.forename: Peter B
authors.initials: PB
authors.lastname: Rosenquist
authors.forename: Benoit H
authors.initials: BH
authors.lastname: Mulsant
authors.forename: Harold A
authors.initials: HA
authors.lastname: Sackeim
mesh_terms: D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D000928:Antidepressive Agents / Q000627:therapeutic use*; D000929:Antidepressive Agents, Tricyclic / Q000627:therapeutic use; D003511:Cyclohexanols / Q000627:therapeutic use; D039721:Diagnostic and Statistical Manual of Mental Disorders; D004351:Drug Resistance; D004522:Educational Status; D004565:Electroconvulsive Therapy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016651:Lithium Carbonate / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009661:Nortriptyline / Q000627:therapeutic use; D011569:Psychiatric Status Rating Scales; D012008:Recurrence; D016019:Survival Analysis; D000069470:Venlafaxine Hydrochloride
chemical_list: D000928:Antidepressive Agents; D000929:Antidepressive Agents, Tricyclic; D003511:Cyclohexanols; D016651:Lithium Carbonate; D000069470:Venlafaxine Hydrochloride; D009661:Nortriptyline