CHAPTER 13: Management of Patient's Post-ECT Course

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.

Since continuation ECT is administered to patients who are in clinical remission, and because long inter-treatment intervals are used, it is typically administered on an ambulatory basis (see Section 11.1). The specific timing of continuation ECT treatments has been the subject of considerable discussion (Kramer 1987b; Fink 1990; Monroe 1991; Scott et al. 1991; Sackeim 1994; Petrides & Fink 1994: Fink et al. 1996; Abrams 1997; Rabheru & Persad 1997; Petrides 1998), but evidence supporting any set regimen is lacking. In many cases, treatments are started on a weekly basis with the interval between treatments gradually extended to a month, depending upon the patient's response. Such a plan is designed to counteract the high likelihood of early relapse noted previously. In general, the greater the likelihood of early relapse, the more intensive the regimen should be. The use of psychotropic agents during a series of continuation ECT remains an unresolved issue (Jarvis et al. 1990; Thornton et al. 1990; Fink et al. 1996; Petrides 1998). Given the resistant nature of many such cases, some practitioners supplement continuation ECT with such medication in selected cases, particularly in those who have limited benefit from continuation ECT alone. In addition, some practitioners believe that the onset of symptoms of impending relapse in ECT responsive patients undergoing continuation pharmacotherapy alone may represent an indication for a short series of ECT treatments for a combination of therapeutic and prophylactic purposes (Grunhaus et al. 1990), although controlled studies are not yet available to substantiate this practice.

Before each continuation ECT treatment, the attending physician should 1) assess clinical status and current medications, 2) make a determination as to whether the treatment is indicated, and decide the timing of the next treatment. A monthly assessment may be used if continuation treatments are occurring at least twice monthly and the patient has been clinically stable for at least 1 month. In any case, the overall treatment plan, including the role of ECT, should be updated at least quarterly. Informed consent should be renewed no less frequently than every 6 months (see Chapter 8). To provide an ongoing assessment of risk factors, an interval medical history, focusing on specific systems at risk with ECT, and vital signs should be done prior to each treatment, with further assessment as clinically indicated. In many settings, this brief evaluation is accomplished by the ECT psychiatrist or anesthetist on the day of the treatment. A full anesthesia pre-operative exam (see Section 6) should be repeated at least every 6 months, and laboratory tests at least annually. Although cognitive effects appear to be less severe with continuation ECT than with the more frequent treatments that are administered during an ECT course (Ezion et al. 1990; Grunhaus et al. 1990; Theinhaus et al. 1990; Thornton et al. 1990; Barnes et al. 1997), monitoring of cognitive function should be done at least every 3 treatments. As discussed in Chapter 12, this may consist of simple bedside assessment of memory function.

13.4. Continuation psychotherapy. For some patients, individual or group psychotherapy may be useful in dealing with underlying psychodynamic issues, in facilitating better ways to cope with stressors that might otherwise precipitate a clinical relapse, in assisting the patient to re-organize his/her social and vocational activities, and in encouraging a return to normal life.

Maintenance therapy. Maintenance therapy is empirically defined herein as the prophylactic use of psychotropics or ECT longer than 12 months past the onset of remission in the index episode. Maintenance treatment is indicated when attempts to stop continuation therapy have been associated with symptom recurrence, when continuation therapy has been only partially successful, or when a strong history of recurrent illness is present (Loo et al. 1990; Thienhaus et al. 1990; Thornton et al. 1990; Vanelle et al. 1994; Stiebel 1995). The specific criteria for maintenance ECT, as opposed to maintenance psychotropic therapy, are the same as those described above for continuation ECT. The frequency of maintenance ECT treatments should be kept to the minimum compatible with sustained remission, with re-evaluation of the need for extension in the treatment series and repeated application of informed consent procedures performed at the intervals listed above for continuation ECT.

RECOMMENDATIONS

13.1. General Considerations

a) Continuation therapy, typically consisting of psychotropic medication or ECT, is indicated for virtually all patients. The rationale behind decisions not to recommend continuation therapy should documented.

b) Continuation therapy should begin as soon as possible after termination of the ECT course, except when presence of adverse ECT effects, e.g., delirium, necessitates a delay.

c) Unless countervened by adverse effects, continuation therapy should be maintained for at least 12 months. Patients with a high risk of recurrence or residual symptomatology will generally require longer-term maintenance therapy.

d) The aim of maintenance therapy is to prevent recurrence of new episodes of the index disorder. It is typically defined as treatment continuing longer than 12 months following completion of the most recent ECT course. Maintenance therapy is indicated when therapeutic response has been incomplete, when a recurrence of clinical symptoms or signs has occurred, or where a history of early relapse is present.

13.2. Continuation/Maintenance Pharmacotherapy

The choice of agent should be determined by the type of underlying illness, a consideration of adverse effects, and response history. In this regard, when clinically feasible, practitioners should consider a class of pharmacologic agents for which the patient did not manifest resistance during the treatment of the acute episode.

13.3. Continuation/Maintenance ECT

13.3.1. General

a) Continuation/Maintenance ECT should be available in programs administering ECT.

b) Continuation/maintenance ECT may be given on either an inpatient or outpatient basis. In the latter case, the recommendations presented in Section 11.1 apply.

13.3.2. Indications for Continuation ECT

a) history of recurring episodic illness which has been responsive to ECT; and

b) either 1) pharmacotherapy alone has not proved effective in preventing relapse or cannot be safely administered for such a purpose; or 2) patient preference; and

c) the patient is agreeable to receive continuation ECT, and is capable, with the assistance of others, of complying with the treatment plan.

13.3.3. Delivery of Treatments

a) Various formats exist for delivering continuation ECT. The timing of treatments should be individualized for each patient, and should be adjusted as necessary with consideration of both beneficial and adverse effects.

b) The duration of continuation ECT should be guided by the factors described in 13.1(b) and 13.1(c).

13.3.4. Maintenance ECT

a) Maintenance ECT is indicated when a need for maintenance treatment (Section 1-3.1(d)) exists in patients already receiving continuation ECT (Section 13.3.2).

b) Maintenance ECT treatments should be administered at the minimum frequency compatible with sustained remission.

c) The continued need for maintenance ECT should be reassessed at least every three months. This assessment should include consideration of both beneficial and adverse effects.

13.3.5. Pre-ECT Evaluation for Continuation/Maintenance ECT

Each facility using continuation/maintenance ECT should devise procedures for pre-ECT evaluation in such cases. The following recommendations are suggested, with the understanding that additions to or increased frequency of evaluative procedures should be included whenever clinically indicated.

a) Prior to each treatment:

1) interval psychiatric evaluation (this evaluation may be done monthly if treatments are at an interval of 2 weeks or less AND the patient has been clinically stable for at least 1 month)

2) interval medical history and vital signs (this exam may be done by the ECT psychiatrist or anesthetist at the time of the treatment session), with additional examination as clinically indicated

b) Updating of overall clinical treatment plan at least every three months.

c) Assessment of cognitive function (see Section 12.2.1) at least every three treatments.

d) At least every six months:

1) consent for ECT (see Chapter 8)

anesthesia preoperative examination

e) Laboratory tests (see Chapter 6) at least yearly.

13.4 Continuation/Maintenance Psychotherapy

Psychotherapy, whether on an individual, group, or family basis, represents a useful component of the clinical management plan for some patients following an index ECT course.