Can ECT Augment Treatment in Treatment-Resistant Depression?
Yes, ECT is highly effective as an augmentation strategy for treatment-resistant depression (TRD), with remission rates exceeding 50% even in severely treatment-resistant patients who have failed multiple medication trials. 1, 2
When to Consider ECT as Augmentation
ECT should be considered after failure of at least two adequate antidepressant trials, defined as 8-10 weeks at therapeutic doses with confirmed adherence. 1 However, ECT may be used as first-line therapy when symptoms are life-threatening, including:
- Refusal to eat or drink 1
- Severe suicidality 1
- Profound psychomotor retardation 1
- Uncontrollable mania 1
- Florid psychosis 1
Evidence for ECT Effectiveness in TRD
ECT remains highly effective even in the most treatment-resistant populations. In patients who had spent an average of 14.6 months in their current depressive episode and failed an average of 5.4 different pharmacological treatments, 65.8% responded and 53.3% achieved remission. 2 Critically, there was no correlation between the number of unsuccessful antidepressant trials and improvement, meaning ECT works regardless of how many medications have failed. 2
ECT demonstrates particular effectiveness in:
- Patients with psychotic features 3
- Patients aged 45 years or older 3
- Severe mood symptoms with agitation 3
Combining ECT with Medications
Antidepressants can be continued during ECT, though the evidence for enhanced efficacy is limited. A randomized controlled trial comparing ECT plus agomelatine versus ECT plus placebo found comparable response/remission rates and no difference in relapse prevention. 4 However, continuing antidepressants during ECT may provide ongoing coverage and help prevent relapse after ECT completion. 3
Specific medication considerations during ECT:
- Discontinue before ECT: Lithium, benzodiazepines, and carbamazepine (due to adverse effect risks) 3
- Can continue: Olanzapine and mirtazapine as part of maintenance strategy 3
- Vortioxetine: Can be continued unless specific side effects emerge 3
Treatment Protocol
A typical ECT course consists of:
- Frequency: Three times weekly (most common in US) or twice weekly 3
- Total treatments: 10-12 sessions 3
- Initial improvement: Often observed after first 5-6 treatments 3
- Electrode placement: Bilateral placement may be preferred for agitated depression with severe symptoms for more rapid response 3
Post-ECT Management
After ECT, patients require continuation treatment to prevent relapse. 1 This should include pharmacotherapy tailored to the presenting disorder. 1 The combination of ECT with depression-specific psychotherapy represents a promising strategy, though research is limited and psychotherapy approaches may need special adaptations due to cognitive effects of ECT. 5
Important Considerations
There are no absolute contraindications to ECT. 1 Conditions previously considered contraindications (cerebral tumors, recent myocardial infarction, active chest infections) are now only relative concerns. 1
Patients who should NOT be excluded from ECT consideration:
- Multiple-drug resistant individuals 6
- Those who failed augmentation strategies 6
- Those who failed structured psychotherapy 6
- Those who failed transcranial magnetic stimulation (TMS) 6
- Patients with personality disorders 1, 3
- Patients with seizure disorders (may even improve with ECT) 1
Patients who failed deep brain stimulation (DBS) or vagus nerve stimulation (VNS) should be excluded from TRD clinical studies but this does not preclude ECT use in clinical practice. 6
Clinical Outcomes
ECT provides significant benefits beyond symptom reduction:
- 50% lower risk of suicide in the first year after discharge compared to those who did not receive ECT 3
- Shorter hospital stays compared to those who refuse ECT 3
- Improved quality of life 3
ECT should not be considered a treatment of last resort but rather should be administered based on individual patient and illness factors, particularly severity and treatment resistance. 7