PRASED – Preventing Relapse After successful ECT for depression
In the current research project, we assess the additional effect of lithium addition in preventing relapse following electroconvulsive therapy (ECT) for depression.
01/01/2019 - 01/12/2022
Violette Coppens, Eline Schellens, Ingrid Vanderplas, Sarah Debruyne
For more information please contact Didier Schrijvers:
Tel. n°: 015304189
Although electroconvulsive therapy (ECT) is a very effective acute treatment for (unipolar as well as bipolar(1,2)) major depression, one of the major challenges in the treatment of mood disorders is to prevent relapse after successful treatment. Without continuation treatment, up to 50% of patients will relapse within 3 months after the last treatment and 6 months relapse rates are as high as 80% (3).
Several strategies have been used to decrease these relapse rates. The most commonly used strategy, pharmacological treatment with antidepressants, decrease 6-month relapse rates by 30% (4,5). Nevertheless, as nearly half of patients on antidepressants will relapse within one year after successful ECT, relapse prevention remains a major challenge (6,7). Other strategies are addition of lithium to antidepressant maintenance treatment or continuation of ECT after the acute course (M-ECT), alone or in combination with antidepressants and/or lithium. These strategies decrease relapse rates to different extents.
In a large RCT, lithium in combination with Nortriptyline reduced 6-month-relapse rates to 32% (8). A recently published audit also found superior results of the combination of an antidepressant with lithium at six months (relapse rate of 16%) (9). Although it is advised to consider lithium combined with an antidepressant as a possible continuation treatment after ECT (10), its effectiveness remains understudied.
M-ECT is a course that begins after the end of the acute ECT course and is intended to prevent relapse of the treated episode occurrence of a new depressive episode (11). Continuation of ECT can be done either at a fixed schedule (slowly tapering of ECT according to a fixed schedule) or personalized (flexible ECT depending on change in the level of depression symptoms). Most studies have used a fixed M-ECT scheme, while clinical practice suggest that a flexible, symptom driven treatment scheme might be more effective in preventing relapse (12). This was confirmed in the recently published PRIDE-study (13). Only 13% of the patients receiving personalized ECT, an antidepressant and lithium had relapsed at six months. This study, however, was limited to elderly patients, who are known to respond better (14) and have a better long-term outcome than the non-elderly (15).
Our project is designed to validate results of the PRIDE-study, not limiting inclusions to older patients, as about half of the patients treated with ECT are non-elderly and relapse prevention in this patient group is as least as challenging. Besides that, we would like to assess the additional effect of lithium addition in preventing relapse with a flexible, symptom-driven and personalized ECT algorithm. After successful brief pulse ECT, patients will be randomized to receive either personalized M-ECT in combination with their ongoing (antidepressant) medication and lithium, or personalized M-ECT in combination with their ongoing (antidepressant) medication without lithium. There will be a follow-up period of one year.
This project enables us to validate the effectiveness of personalized M-ECT, and to assess the effectiveness of lithium as part of a relapse prevention strategy post-ECT. Improving relapse prevention is ‘the most pressing issue in the field’ (7), with an added value for the group of patients with depression that were treated with ECT. As this is only scarcely been investigated, it leaves the clinician without clear
guidance on the best treatment strategy after successful ECT. Although our main goal is a positive medical impact, reducing relapse rates eventually also has a socio-economic influence by reducing health care costs.
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