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Speed of remission in elderly patients with depression: Electroconvulsive therapy v. medication

  • Harm-Pieter Spaans (a1), Pascal Sienaert (a2), Filip Bouckaert (a2), Julia F. van den Berg (a1), Esmée Verwijk (a1), King H. Kho (a1), Max L. Stek (a3) and Rob M. Kok (a1)...
Abstract
Background

Severe depression can be a life-threatening disorder, especially in elderly patients. A fast-acting treatment is crucial for this group. Electroconvulsive therapy (ECT) may work faster than medication.

Aims

To compare the speed of remission using ECT v. medication in elderly in-patients.

Method

The speed of remission in in-patients with a DSM-IV diagnosis of major depression (baseline MADRS score $20) was compared between 47 participants (mean age 74.0 years, s.d. = 7.4) from an ECT randomised controlled trial (RCT) and 81 participants (mean age 72.2 years, s.d. = 7.6) from a medication RCT (nortriptyline v. venlafaxine).

Results

Mean time to remission was 3.1 weeks (s.d. = 1.1) for the ECT group and 4.0 weeks (s.d. = 1.0) for the medication group; the adjusted hazard ratio for remission within 5 weeks (ECT v. medication) was 3.4 (95% CI 1.9–6.2).

Conclusions

Considering the substantially higher speed of remission, ECT deserves a more prominent position in the treatment of elderly patients with severe depression.

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Copyright
Corresponding author
Harm-Pieter Spaans, MD, Parnassia Psychiatric Institute, Clinical Centre for the Elderly, Mangostraat 1, 2552 KS The Hague, The Netherlands. Email: hp.spaans@parnassia.nl
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 World Health Organization. Prevention of Mental Disorders: Effective Interventions and Policy Options: Summary Report. A Report of the World Health Organization Department of Mental Health and Substance Abuse; in collaboration with the Prevention Research Centre of the Universities of Nijmegen and Maastricht. World Health Organization, 2004.
2 Shahly, V, Chatterji, S, Gruber, MJ, Al-Hamzawi, A, Alonso, J, Andrade, LH, et al. Cross-national differences in the prevalence and correlates of burden among older family caregivers in the World Health Organization World Mental Health (WMH) Surveys. Psychol Med 2013; 43: 865–79.
3 Beekman, AT, Copeland, JR, Prince, MJ. Review of community prevalence of depression in later life. Br J Psychiatry 1999; 174: 307–11.
4 Baldwin, RC. Poor prognosis of depression in elderly people: causes and actions. Ann Med 2000; 32: 252–6.
5 National Collaborating Centre for Mental Health. Depression: The NICE Guideline on the Treatment and Management of Depression in Adults. British Psychological Society and Royal College of Psychiatrists, 2010.
6 Weiner, RD. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging (A Task Force Report of the American Psychiatric Association). American Psychiatric Association, 2001.
7 Van den Broek, WW, Birkenhäger, TK, de Boer, D, Burggraaf, JP, van Gemert, B, Groenland, THN, et al. Richtlijn Elektroconvulsietherapie (Guideline Electroconvulsive Therapy). de Tijdstroom, 2010.
8 O'Connor, MK, Knapp, R, Husain, M, Rummans, TA, Petrides, G, Smith, G, et al. The influence of age on the response of major depression to electroconvulsive therapy: a C.O.R.E. Report. Am J Geriatr Psychiatry 2001; 9: 382–90.
9 Tew, JD Jr, Mulsant, BH, Haskett, RF, Prudic, J, Thase, ME, Crowe, RR, et al. Acute efficacy of ECT in the treatment of major depression in the old-old. Am J Psychiatry 1999; 156: 1865–70.
10 van der Wurff, FB, Stek, ML, Hoogendijk, WJ, Beekman, AT. Discrepancy between opinion and attitude on the practice of ECT by psychiatrists specializing in old age in the Netherlands. J ECT 2004; 20: 3741.
11 Stek, ML, Wurff van der, FB, Hoogendijk, WJG, Beekman, ATF. Electroconvulsive therapy for the depressed elderly. Cochrane Database Syst Rev 2009; 4: 4.
12 Flint, AJ, Rifat, SL. The treatment of psychotic depression in later life: a comparison of pharmacotherapy and ECT. Int J Geriatr Psychiatry 1998; 13: 23–8.
13 Thase, ME. Evaluating antidepressant therapies: remission as the optimal outcome. J Clin Psychiatry 2003; 64 (suppl 13): 1825.
14 Stek, ML, van der Wurff, FB, Uitdehaag, BM, Beekman, AT, Hoogendijk, WJ. ECT in the treatment of depressed elderly: lessons from a terminated clinical trial. Int J Geriatr Psychiatry 2007; 22: 1052–4.
15 Spaans, HP, Verwijk, E, Comijs, HC, Kok, RM, Sienaert, P, Bouckaert, F, et al. Efficacy and cognitive side effects after brief pulse and ultrabrief pulse right unilateral electroconvulsive therapy for major depression: a randomized, double-blind, controlled study. J Clin Psychiatry 2013; 74: e102936.
16 Kok, RM, Nolen, WA, Heeren, TJ. Venlafaxine versus nortriptyline in the treatment of elderly depressed inpatients: a randomised, double-blind, controlled trial. Int J Geriatr Psychiatry 2007; 22: 1247–54.
17 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder (4th edn) (DSM-IV). APA, 1994.
18 Montgomery, SA, Åsberg, M. A new depression scale designed to be sensitive to change. Br J Psychiatry 1979; 134: 382–9.
19 Hamilton, M. Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol 1967; 6: 278–96.
20 Sheehan, DV, Lecrubier, Y, Sheehan, KH, Amorim, P, Janavs, J, Weiller, E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998; 59 (suppl 20): 2233; quiz 34–57.
21 Hiller, W, Zaudig, M, Mombour, W. Development of diagnostic checklists for use in routine clinical care. A guideline designed to assess DSM-III-R diagnoses. Arch Gen Psychiatry 1990; 47: 782–4.
22 Nobler, MS, Sackeim, HA, Moeller, JR, Prudic, J, Petkova, E, Waternaux, C. Quantifying the speed of symptomatic improvement with electroconvulsive therapy: comparison of alternative statistical methods. Convuls Ther 1997; 13: 208–21.
23 Oudega, ML, van Exel, E, Wattjes, MP, Comijs, HC, Scheltens, P, Barkhof, F, et al. White matter hyperintensities, medial temporal lobe atrophy, cortical atrophy, and response to electroconvulsive therapy in severely depressed elderly patients. J Clin Psychiatry 2011; 72: 104–12.
24 Nordenskjold, A, von Knorring, L, Engstrom, I. Predictors of the short-term responder rate of electroconvulsive therapy in depressive disorders – a population based study. BMC Psychiatry 2012; 12: 115.
25 Selvan, CP, Mayur, PM, Gangadhar, BN, Janakiramaiah, N, Subbakrishna, DK, Murali, N. Comparison of therapeutic efficacy of ECT and imipramine: a randomized controlled trial. Indian J Psychiatry 1999; 41: 228–35.
26 Folkerts, HW, Michael, N, Tolle, R, Schonauer, K, Mucke, S, Schulze-Monking, H. Electroconvulsive therapy vs. paroxetine in treatment-resistant depression – a randomized study. Acta Psychiatr Scand 1997; 96: 334–42.
27 Dinan, TG, Barry, S. A comparison of electroconvulsive therapy with a combined lithium and tricyclic combination among depressed tricyclic nonresponders. Acta Psychiatr Scand 1989; 80: 97100.
28 Dombrovski, AY, Mulsant, BH, Haskett, RF, Prudic, J, Begley, AE, Sackeim, HA. Predictors of remission after electroconvulsive therapy in unipolar major depression. J Clin Psychiatry 2005; 66: 1043–9.
29 Kho, KH, Zwinderman, AH, Blansjaar, BA. Predictors for the efficacy of electroconvulsive therapy: chart review of a naturalistic study. J Clin Psychiatry 2005; 66: 894–9.
30 Joel, I, Begley, AE, Mulsant, BH, Lenze, EJ, Mazumdar, S, Dew, MA, et al. Dynamic prediction of treatment response in late-life depression. Am J Geriatr Psychiatry 2014; 22: 167–76.
31 Kok, RM, Nolen, WA, Heeren, TJ. Outcome of late-life depression after 3 years of sequential treatment. Acta Psychiatr Scand 2009; 119: 274–81.
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Speed of remission in elderly patients with depression: Electroconvulsive therapy v. medication

  • Harm-Pieter Spaans (a1), Pascal Sienaert (a2), Filip Bouckaert (a2), Julia F. van den Berg (a1), Esmée Verwijk (a1), King H. Kho (a1), Max L. Stek (a3) and Rob M. Kok (a1)...
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eLetters

RE: Speed of remission in elderly patients with depression: electroconvulsive therapy v. medication

This article made an interesting reading. This study has touched a pertinent clinical issue. Arrival of new antidepressants has fueled the controversy related to the use of ECT even further. Scarcity of data1 and reluctance of psychiatrists2 to use ECT in elderly have led to underuse of this effective treatment modality in elderly with depressive disorder. This study is an important effort in this direction. However there are certain issues that need to be taken into account while evaluating the results of this study.

First, use of two different tools i.e. Mini International Neuropsychiatric Interview (MINI) in ECT trial group and the International Diagnosis Check List (IDCL) in medication trial group for the confirmation of diagnosis cast doubt regarding the diagnostic homogeneity of two groups as MINI is compatible with DSM-IV and IDCL with DSM-III-R.

Second, though both the study groups were comparable and p value for MADRS and HRSD not significant but ideally p value for 2 groups should be zero. Further, both groups comparable on psychotic features but not using antipsychotic drugs along with antidepressants in medication trial group might have halted the recovery in this group.

It would have been better if authors would have compared and discussed their results with similar studies rather than with the ones studying rate of response.

On the whole it is a commendable research not only in ECT but also for ECT in elderly.

Reference:

1. Stek ML, Wurff van der FB, Hoogendijk WJG, Beekman ATF. Electroconvulsive

therapy for the depressed elderly. Cochrane Database Syst Rev 2009; 4: 4.

2. van der Wurff FB, Stek ML, Hoogendijk WJ, Beekman AT. Discrepancy

between opinion and attitude on the practice of ECT by psychiatrists

specializing in old age in the Netherlands. J ECT 2004; 20: 37–41.

... More

Conflict of interest: None Declared

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Relevance of Study

Saurabh Saxena, ST yr4
06 February 2015

Dear Authors, Thank you for your sincere efforts in presenting this interesting article.This study compares speed of remission in inpatients with diagnosis of severe depression between ECT randomised controlled trial (1)and medication (nortryptiline v. venlafaxine) RCT (2). My question would be that how often in the inpatient setting do we initiate monotherapy of nortyiptyline or venlafaxine and continue for 5 weeks without changing/ augmenting the medication regime in a patient with severe depression if there is no improvement in the patient with severe depression. We usually get a patient with severe depression admitted from community when he is already on combination of two antidepressants or a combination of one antidepressant and one antipsychotic/ mood stabiliser. And if this is the case then we can challenge the relevance of this study and I feel comparing efficacy of ECT with more robust drug regimes may be more beneficial.Your article mentions a RCT that compared ECT with the addition of lithiumin a group of patients treated with tricyclic antidepressants; lithium addition resulted in a significant improvement in first week (3). I would like more such studies that compare interventions which we are likely to confront/ use in our clinical practice. Besides comparing efficacy, I would also like to see the comparison of side effects in short term and long term, if possible, to help with my decision making.However, I do agree that ECT is relatively safe and effective in elderly population but there is some reluctance in clinicians to prescribe ECT andthis article would help guide the clinicians formulating their treatment plans more confidently.

1. Spaans HP, Verwijk E, Comijs HC, Kok RM, Sienaert P, Bouckaert F, et al. Efficacy and cognitive side effects after brief pulse and ultrabrief pulse right unilateral electroconvulsive therapy for major depression: a randomized, double-blind, controlled study. J Clin Psychiatry 2013; 74: e1029-36.2. Kok RM, Nolen WA, Heeren TJ. Venlafaxine versus nortriptyline in the treatment of elderly depressed inpatients: a randomised, double-blind, controlled trial. Int J Geriatr Psychiatry 2007; 22: 1247-54. 3. Dinan TG, Barry S. A comparison of electroconvulsive therapy with a combined lithium and tricyclic combination among depressed tricyclic nonresponders. Acta Psychiatr Scand 1989; 80: 97-100

... More

Conflict of interest: None declared

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Akintunde Alabi, Psychiatric Registrar
02 February 2015

We read with interest your article and were really impressed by your study design, as it may be quite difficult for ethical as well as practical reasons to carry out a randomized controlled trial in which ECT is directly compared with antidepressants in elderly severely depressed patients. We noticed in the ECT study[1], it appears antidepressants as well as Lithium were continued in the patients receiving ECT. As there is some evidence for the benefit of combining antidepressants with ECT [2], we wondered if the speed of efficacy seen in your study may have been due to a combination of ECT and medications and not just ECT alone.

But overall, we think your study contributes to the evidence for the benefit of ECT in the elderly, most especially as decisions to treat elderly depressed patients with ECT could be faced with hesitation at times. [3]

1. Spaans H, Verwiik, Comis H et al (2013) Efficacy and cognitive side effects after brief pulse and ultrabrief pulse right unilateral electroconvulsive therapy for major depression : a randomized double-blindcontrolled study. J Clin Psychiatry 74: e1029-36.2. Sackeim H, Dillingham E, Prudic J et al(2009). Effect of Concomitant Pharmacotherapy on Electroconvulsive Therapy Outcomes Short- term Efficacyand Adverse Effects. Arch Gen Psychiatry 66(7):729-737. 3. Benbow S (1991) Old people and ECT: what difficulties are encountered in obtaining anaesthetics for the elderly? Psychiatric Bullettin 15, 324-325.

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Conflict of interest: None declared

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