Third-Line Electroconvulsive Therapy May Be Best for Patients With Treatment-Resistant Depression

Clinicians may want to consider electroconvulsive therapy (ECT) for patients with major depressive disorder who have failed to respond to two trials of pharmacotherapy and/or psychotherapy, according to the authors of a study published this week in JAMA Psychiatry.

“As clinicians we always worry about patients getting routed through treatment after treatment, at which point they become more treatment resistant,” senior author Daniel Maixner, M.D., who directs the ECT program at Michigan Medicine, told Psychiatric News. Decades of research have shown that ECT is the most effective way of achieving remission in patients with treatment-resistant depression (TRD), he noted. The findings of this study suggest ECT is also cost-effective earlier in the treatment course of depression.

Relying on data from published depression studies, including the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) trial, Maixner, Eric Ross, M.D., and Kara Zivin, Ph.D., of the University of Michigan Department of Psychiatry used a mathematical model to simulate cost and quality-of-life outcomes for patients with TRD who are exposed to different treatments.

The model projected that over four years, ECT would reduce time with uncontrolled depression from 50% of life-years to between 32% and 37% of life-years, with greater improvements the earlier ECT is offered. The model also predicted that offering ECT as a third-line treatment for depression would cost an estimated $54,000 per quality-adjusted life-year gained, well below the commonly accepted cost-effectiveness threshold of $100,000 per quality-of-life year, according to the authors.

Ross noted that cost-effectiveness does not mean cost saving. “When we say ECT is cost-effective, we are not saying that it’s going to save money, but we are saying that the money that is spent on ECT will get a very good return in terms of its improvement in health.”

The authors acknowledged that many clinicians may find ECT as a third-line treatment to be “overly aggressive,” as ECT is often considered a “last-resort treatment for depression.” They wrote, “To understand how third-line ECT can be reasonable and cost-effective, it is crucial to recognize how challenging treatment-resistant depression is to manage.”

Charles Kellner, M.D., chief of Electroconvulsive Therapy at New York Community Hospital in Brooklyn, N.Y., who was not involved with the study, spoke enthusiastically of the findings. “I think this is a landmark study,” he told Psychiatric News. “The importance of the article is that it finally provides data for a rationale to use ECT earlier rather than at the very end of other treatment options. It is what the field has needed to put ECT in the correct context.”

For related information, see the Psychiatric News article “ECT Can Be Considered Earlier for Severe Depression, Expert Says.”

(iStock/AJ_Watt)

Follow Psychiatric News on Twitter!

Technical, Clinical Advances Make ECT Safe, More Effective for More Patients

Electroconvulsive therapy (ECT) should be regarded as a valuable treatment for severe major depression based on severity of illness, “not just because all other treatments have failed,” said Charles Kellner, M.D., the chief of electroconvulsive therapy at New York Community Hospital, Brooklyn, during a workshop Saturday at APA’s fall meeting IPS: The Mental Health Services Conference in New Orleans.

Technical and clinical advances have vastly improved the effectiveness and tolerability of ECT for patients with severe depression, and research is now beginning to elucidate how ECT works, he said. Kellner was joined at the session by Robert Greenberg, M.D., chief of geriatric psychiatry at New York University Langone Health, Brooklyn Campus; Adriana Hermida, M.D., of Emory University School of Medicine; and Robert Cotes, M.D., associate director of psychiatry residency education at Emory.

Advances in ECT include technical improvements such as the development of ultra-brief pulse wave ECT. This type of ECT has been shown to substantially diminish the risk of cognitive effects, the biggest fear among patients and family members regarding the treatment. “Modern ECT causes far less retrograde amnesia [than in the past],” Kellner said. “For seriously depressed patients, [concern about this side effect] should not be a deal-breaker.”

Despite improvements in ECT technology and evidence of the effectiveness of the therapy, Kellner told session attendees that the “biggest obstacle to the use of ECT are reservations about the treatment that cannot be explained [rationally].”

Kellner noted that allowing family members to be present for administration of ECT is an important way to diminish stigma about the treatment. “For many family members it is beneficial for them to stay in the treatment suite for the entire procedure,” Kellner said. “Family members are relieved to see that ECT is banal, quick, smooth, and safe.”

Kellner added that there have been new diagnostic indications for ECT, such as for treatment of self-injurious behavior related to autism. He added that the Centers for Medicare and Medicaid Services (CMS) is considering approval of a code for use of ECT in ambulatory surgical centers. “If that becomes available, it will be a major breakthrough for ECT access,” Kellner said.

Look for further coverage of IPS: The Mental Health Services conference in Psychiatric News.