What is the relapse risk after discontinuing electroconvulsive therapy (ECT) and what maintenance strategies are recommended to prevent relapse?

Relapse Risk After ECT Discontinuation

ECT is highly effective for acute treatment but does not prevent relapse—without continuation treatment, approximately 40-60% of patients will relapse, with the highest risk occurring in the first 3-8 months after discontinuation. 1

Evidence of Relapse Rates

After Acute ECT Course

• Relapse occurs in 40-60% of patients within the first year even with adequate antidepressant continuation pharmacotherapy 2, 3
• The risk is greatest during the first 3 months, with most relapses occurring within this critical window 2, 4
• All relapses in one study occurred within the first 8 months after ECT discontinuation 2

After Maintenance ECT Discontinuation

• Approximately 44-61% of patients relapse within 6 months when maintenance ECT is stopped 2, 4, 5
• The median time to relapse after abrupt M-ECT discontinuation is 8 weeks 4
• Relapse rates after M-ECT discontinuation are similar to those after acute ECT, underscoring the chronic nature of these illnesses 4

High-Risk Populations for Relapse

Diagnostic Factors

• Patients with psychotic disorders (schizophrenia, schizoaffective disorder) have significantly higher relapse rates compared to those with major depressive disorder 2, 4
• Bipolar II disorder is associated with increased relapse risk compared to unipolar depression 6
• Patients with major depressive disorder alone have the lowest relapse rates 2

Treatment History Factors

• Greater number of previous acute ECT courses strongly predicts higher relapse risk 4, 6
• Larger number of previous depressive episodes increases relapse vulnerability 6
• Patients requiring more frequent M-ECT intervals (1-2 week spacing) at discontinuation are at substantially higher risk 4, 5

Protective Factors

• Older age (>60 years) is associated with lower relapse risk and longer time to relapse 6, 5
• Presence of psychotic symptoms before ECT paradoxically predicts lower relapse risk in some studies 6
• Lithium maintenance therapy appears protective against relapse 6

Mandatory Continuation Strategies

Pharmacotherapy Requirements

The American Academy of Child and Adolescent Psychiatry explicitly states that ECT will not prevent relapse and an effective continuation treatment strategy is necessary. 1

• For unipolar major depressive disorder: Initiate antidepressant medication before completing the ECT course 1
• For bipolar disorder: Use mood stabilizers as primary maintenance treatment 1
• For psychotic disorders: Consider combination of mood stabilizers and/or neuroleptic agents 1
• Pharmacotherapy selection should be based on treatment history, family response history, or novel agents if prior treatments failed 1

Maintenance ECT Considerations

• Maintenance ECT is successfully used in adults with mood disorders to prevent relapse 1
• For patients who relapse despite adequate pharmacotherapy, maintenance ECT should be strongly considered rather than discontinued 2, 3
• Patients requiring frequent M-ECT intervals should be considered for permanent maintenance ECT rather than discontinuation 2

Psychotherapy Integration

• Individual psychotherapy (supportive or cognitive-behavioral) should be tailored to patient needs 1
• Family therapy may be indicated depending on the clinical situation 1

Critical Monitoring Protocol

Immediate Post-ECT Period

• Monitor for mood changes and suicidal ideation for several weeks after ECT completion 1
• Use standardized rating scales to systematically assess treatment outcomes 1
• Evaluate cognition, mood, psychosis, and other psychiatric symptoms at regular intervals 1

After M-ECT Discontinuation

• Intensive monitoring is crucial in the first 3 months, when relapse risk is highest 2, 4, 5
• Continue close follow-up through 8 months, as all relapses occur within this timeframe 2
• Watch for early warning signs of relapse, particularly in high-risk patients 5

Common Pitfalls to Avoid

• Never discontinue ECT without establishing continuation treatment first—this is the single most critical error leading to relapse 1
• Do not assume ECT provides lasting protection—it treats the acute episode only and has no prophylactic effect 1
• Avoid premature M-ECT discontinuation in patients with psychotic disorders, multiple prior ECT courses, or those requiring frequent treatment intervals 2, 4
• Do not underestimate relapse risk—even with optimal pharmacotherapy, 40-60% will relapse 2, 3