Data support ECT for depression, other mood disorders in elderly

LOS ANGELES – Data continue to affirm the efficacy of electroconvulsive therapy, or ECT, for the treatment of major depression and other mood disorders, and numerous studies show that the benefits are particularly pronounced in older patients.

ECT experts at the annual meeting of the American Association for Geriatric Psychiatry shared some of these findings, along with newer data on optimal electrode placement, and an emerging indication for electroconvulsive therapy.

CORE age-related findings

Among adults aged 18-85 who were treated with ECT for unipolar depression in one study, for example, older patients responded better than did younger patients, Dr. Georgios Petrides said.

That study, the first from CORE (the Consortium for Research in Electroconvulsive Therapy), compared ECT with combination antidepressant/antipsychotic pharmacotherapy as a strategy for depression relapse prevention in 201 patients who had remitted after a course of bilateral ECT. Patients from five sites were randomized to receive either 10 continuation ECT treatments or 6 months of treatment with lithium and nortriptyline, said Dr. Petrides of the department of psychiatry at the Albert Einstein College of Medicine, New York, and director of ECT research at the Zucker Hillside Hospital, Glen Oaks, N.Y.

Both groups fared better than a historical placebo control group, but did not differ significantly from each other with respect to remission rates; 46% of patients in both groups remained in remission. Also, no differences were seen between the groups with respect to time to relapse among those who did not remain in remission (Arch. Gen. Psychiatry 2006;63:1337-44).

However, a later analysis of CORE data by age (18-45 years; 46-64 years; and 65 years and older) showed that the remission rates were significantly greater – at up to 90% – for the older patients, compared with the youngest group, Dr. Petrides said.

Of note, relapse rates were lower among patients with psychotic depression, compared with those with non-psychotic depression, and the age-based advantage also was apparent among those with psychotic depression, he said.

Age and electrode placement

A more recent CORE study looking at electrode placement for optimal efficacy and minimal cognitive impairment demonstrated age-based differences in outcomes as well.

In a randomized, controlled, double-blind trial, outcomes in 230 patients with major depression and a mean age of nearly 60 years were found to be similar with a novel bifrontal placement using 1.5 times the seizure threshold, a standard bitemporal placement using 1.5 times the seizure threshold, and with standard right unilateral placement using 6 times seizure threshold, Dr. Charles H. Kellner said.

All placements resulted in clinically and statistically significant improvements, with remission rates, based on strict remission criteria, of 61%, 64%, and 55% for the bifrontal, bitemporal, and right unilateral placements, respectively.

Using less strict criteria for response rather than remission, the rates for the three groups were 79%, 82%, and 73%%, respectively, noted Dr. Kellner, professor of psychiatry and director of the division of geriatric psychiatry at Mount Sinai School of Medicine, New York (Br. J. Psychiatry 2010;196:226-34).

A more rapid decline in symptoms was seen with bitemporal placement.

"So the take-home message there, is that if you have an urgently ill patient, either psychiatrically or medically, than bilateral electrode placement should be considered for them," said Dr. Kellner, who also is director of the ECT service at Mount Sinai Hospital.

Also of note, the remission rate was "remarkably greater" with right unilateral electrode placement in those over age 65 years, compared with younger patients (nearly 75% vs. about 40%-50%), and the remission rate was worse for bifrontal placement in those over age 65 years, compared with younger patient (about 45% vs. 65%).

"If this finding is replicated – and we’ve already partially replicated it (in the Prolonging Remission in Depressed Elderly [PRIDE] study)," he said. "This is good news that for geriatric patients, right unilateral ECT, the more benign form of the treatment, may be preferentially effective."

The finding that certain placements are better or worse in certain patients or age groups underscores the need for making all placements available, and choosing the one that is most appropriate for a patient’s individual circumstances, and the finding that all three electrode placements are effective underscores the argument that "ECT in contemporary practice is not a technical issue." He added, explaining that the data are clear about the effects of ECT, and that it is important to "fight to continue to get it accepted as a standard treatment – to move it up on the treatment algorithm so it is not considered a last resort for treatment."

Among the concerns about ECT that have impeded efforts to "move it up on the treatment algorithm" are those having to do with cognitive effects. Cognitive effects should be considered a tolerability issue rather than a safety issue when it comes to ECT, but regardless, in this study, almost no differences were found with respect to cognitive effects between the three placements studied, he said.

One exception was with reorientation.

"Patients wake up much more easily from right unilateral ECT," he said, noting that this also appears true in the PRIDE study, which is an ongoing evaluation of right unilateral ultrabrief pulse ECT.

Right unilateral ultrabrief pulse ECT

Preliminary data from the PRIDE trial also suggest that right unilateral ultrabrief pulse ECT is extremely effective in elderly patients: Of the first 152 patients from that study, 62% experienced remission, 11% did not, and 27% dropped out of the study.

The patients in that multicenter study have a mean age of 70 years and severe depression.

An interesting finding is that a small percentage of patients "get completely well with a short course of ECT," Dr. Kellner said.

Although most require the usual treatment course and some might require a longer treatment course, some remit very quickly. Thus, it is inappropriate to prescribe a fixed number of treatments in advance.

Also, as has been well documented in other ECT studies, outcomes with right unilateral ultrabrief pulse ECT improve with age.

"The older you get, the better ECT works," he said.

Remission rates were 62%-67% for those aged 70-79 years and 80 years or older, compared with 59% for those aged 60-69 years.

An emerging ECT indication: agitation

Among newer indications for ECT in older patients is agitation in dementia, according to Dr. Robert M. Greenberg.

Dementia is generally not a contraindication to ECT, and although most data on ECT in dementia involve patients with comorbid depression and/or psychosis, many case reports and two small case series suggest that it is effective for agitation alone in patients with dementia, said Dr. Greenberg, director of geriatric services and chief of geriatric psychiatry and ECT services at Lutheran Medical Center, Brooklyn, N.Y.

Behavioral and psychological symptoms, including agitation, occurs at some point in up to 90% of patients with dementia, and agitation and aggression occur in 60%-80% of patients with Alzheimer’s disease. These symptoms account for much of the functional impairment, caregiver burden, hospitalization, and health care costs in dementia patients, and treatment options are limited, he said.

Case reports over the past 2 decades suggest that anywhere from two to eight courses of ECT result in up to 12 months of improvement in symptoms, in some cases with monthly maintenance ECT or repeat courses.

In the largest retrospective case series published to date, 15 of 16 patients who underwent a mean of nine treatments – mostly administered bilaterally – experienced improvement in symptoms, Dr. Greenberg said.

Patients in that study included eight patients with Alzheimer’s disease. Three had mild dementia, eight had moderate-to-severe dementia, and five had severe dementia. Only two patients experienced severe postictal confusion (Am. J. Geriatr. Psychiatry 2012;20:61-72).

Although the evidence base for ECT for agitation in dementia remains fairly weak, the existing data do provide some support for its use. In the cases reported, ECT was usually a last resort after failure of multiple pharmacologic and nonpharmacologic approaches, the impact of behavioral disturbance was severe, and reported benefits were usually of major clinical significance, Dr. Greenberg said, noting also that when addressed, global cognitive function was usually improved following ECT.

Thus, ECT is a reasonable option for dementia with severe agitation in cases after a careful diagnostic evaluation, including assessment for inciting/exacerbating causes, and after failure of behavioral and pharmacologic management.

In patients for whom ECT is deemed appropriate – and for whom proper consent is obtained – Dr. Greenberg recommended starting with titrated unilateral ultrabrief pulse stimulus (in nonemergent cases), and widening the treatment interval if the patients experience significant cognitive worsening.

ECT should be stopped when improvement plateaus, he said.

Also, consider an ECT taper to ensure stability of response and to allow for optimization of continuation pharmacotherapy, he said.

Continuation ECT can be considered if symptoms recur.

Environmental triggers of agitation also should be addressed, he said.

Dr. Petrides and Dr. Greenberg reported having no disclosures relevant to their presentations. Dr. Kellner reported receiving research support from the National Institute of Mental Health. He also reported serving as a paid contributor to UpToDate, a clinical decision support service and as a paid ECT course teacher at Northshore-LIJ Health System.

LOS ANGELES – Data continue to affirm the efficacy of electroconvulsive therapy, or ECT, for the treatment of major depression and other mood disorders, and numerous studies show that the benefits are particularly pronounced in older patients.

ECT experts at the annual meeting of the American Association for Geriatric Psychiatry shared some of these findings, along with newer data on optimal electrode placement, and an emerging indication for electroconvulsive therapy.

CORE age-related findings

Among adults aged 18-85 who were treated with ECT for unipolar depression in one study, for example, older patients responded better than did younger patients, Dr. Georgios Petrides said.

That study, the first from CORE (the Consortium for Research in Electroconvulsive Therapy), compared ECT with combination antidepressant/antipsychotic pharmacotherapy as a strategy for depression relapse prevention in 201 patients who had remitted after a course of bilateral ECT. Patients from five sites were randomized to receive either 10 continuation ECT treatments or 6 months of treatment with lithium and nortriptyline, said Dr. Petrides of the department of psychiatry at the Albert Einstein College of Medicine, New York, and director of ECT research at the Zucker Hillside Hospital, Glen Oaks, N.Y.

Both groups fared better than a historical placebo control group, but did not differ significantly from each other with respect to remission rates; 46% of patients in both groups remained in remission. Also, no differences were seen between the groups with respect to time to relapse among those who did not remain in remission (Arch. Gen. Psychiatry 2006;63:1337-44).

However, a later analysis of CORE data by age (18-45 years; 46-64 years; and 65 years and older) showed that the remission rates were significantly greater – at up to 90% – for the older patients, compared with the youngest group, Dr. Petrides said.

Of note, relapse rates were lower among patients with psychotic depression, compared with those with non-psychotic depression, and the age-based advantage also was apparent among those with psychotic depression, he said.

Age and electrode placement

A more recent CORE study looking at electrode placement for optimal efficacy and minimal cognitive impairment demonstrated age-based differences in outcomes as well.

In a randomized, controlled, double-blind trial, outcomes in 230 patients with major depression and a mean age of nearly 60 years were found to be similar with a novel bifrontal placement using 1.5 times the seizure threshold, a standard bitemporal placement using 1.5 times the seizure threshold, and with standard right unilateral placement using 6 times seizure threshold, Dr. Charles H. Kellner said.

All placements resulted in clinically and statistically significant improvements, with remission rates, based on strict remission criteria, of 61%, 64%, and 55% for the bifrontal, bitemporal, and right unilateral placements, respectively.

Using less strict criteria for response rather than remission, the rates for the three groups were 79%, 82%, and 73%%, respectively, noted Dr. Kellner, professor of psychiatry and director of the division of geriatric psychiatry at Mount Sinai School of Medicine, New York (Br. J. Psychiatry 2010;196:226-34).

A more rapid decline in symptoms was seen with bitemporal placement.

"So the take-home message there, is that if you have an urgently ill patient, either psychiatrically or medically, than bilateral electrode placement should be considered for them," said Dr. Kellner, who also is director of the ECT service at Mount Sinai Hospital.

Also of note, the remission rate was "remarkably greater" with right unilateral electrode placement in those over age 65 years, compared with younger patients (nearly 75% vs. about 40%-50%), and the remission rate was worse for bifrontal placement in those over age 65 years, compared with younger patient (about 45% vs. 65%).

"If this finding is replicated – and we’ve already partially replicated it (in the Prolonging Remission in Depressed Elderly [PRIDE] study)," he said. "This is good news that for geriatric patients, right unilateral ECT, the more benign form of the treatment, may be preferentially effective."

The finding that certain placements are better or worse in certain patients or age groups underscores the need for making all placements available, and choosing the one that is most appropriate for a patient’s individual circumstances, and the finding that all three electrode placements are effective underscores the argument that "ECT in contemporary practice is not a technical issue." He added, explaining that the data are clear about the effects of ECT, and that it is important to "fight to continue to get it accepted as a standard treatment – to move it up on the treatment algorithm so it is not considered a last resort for treatment."

Among the concerns about ECT that have impeded efforts to "move it up on the treatment algorithm" are those having to do with cognitive effects. Cognitive effects should be considered a tolerability issue rather than a safety issue when it comes to ECT, but regardless, in this study, almost no differences were found with respect to cognitive effects between the three placements studied, he said.

One exception was with reorientation.

"Patients wake up much more easily from right unilateral ECT," he said, noting that this also appears true in the PRIDE study, which is an ongoing evaluation of right unilateral ultrabrief pulse ECT.

Right unilateral ultrabrief pulse ECT

Preliminary data from the PRIDE trial also suggest that right unilateral ultrabrief pulse ECT is extremely effective in elderly patients: Of the first 152 patients from that study, 62% experienced remission, 11% did not, and 27% dropped out of the study.

The patients in that multicenter study have a mean age of 70 years and severe depression.

An interesting finding is that a small percentage of patients "get completely well with a short course of ECT," Dr. Kellner said.

Although most require the usual treatment course and some might require a longer treatment course, some remit very quickly. Thus, it is inappropriate to prescribe a fixed number of treatments in advance.

Also, as has been well documented in other ECT studies, outcomes with right unilateral ultrabrief pulse ECT improve with age.

"The older you get, the better ECT works," he said.

Remission rates were 62%-67% for those aged 70-79 years and 80 years or older, compared with 59% for those aged 60-69 years.

An emerging ECT indication: agitation

Among newer indications for ECT in older patients is agitation in dementia, according to Dr. Robert M. Greenberg.

Dementia is generally not a contraindication to ECT, and although most data on ECT in dementia involve patients with comorbid depression and/or psychosis, many case reports and two small case series suggest that it is effective for agitation alone in patients with dementia, said Dr. Greenberg, director of geriatric services and chief of geriatric psychiatry and ECT services at Lutheran Medical Center, Brooklyn, N.Y.

Behavioral and psychological symptoms, including agitation, occurs at some point in up to 90% of patients with dementia, and agitation and aggression occur in 60%-80% of patients with Alzheimer’s disease. These symptoms account for much of the functional impairment, caregiver burden, hospitalization, and health care costs in dementia patients, and treatment options are limited, he said.

Case reports over the past 2 decades suggest that anywhere from two to eight courses of ECT result in up to 12 months of improvement in symptoms, in some cases with monthly maintenance ECT or repeat courses.

In the largest retrospective case series published to date, 15 of 16 patients who underwent a mean of nine treatments – mostly administered bilaterally – experienced improvement in symptoms, Dr. Greenberg said.

Patients in that study included eight patients with Alzheimer’s disease. Three had mild dementia, eight had moderate-to-severe dementia, and five had severe dementia. Only two patients experienced severe postictal confusion (Am. J. Geriatr. Psychiatry 2012;20:61-72).

Although the evidence base for ECT for agitation in dementia remains fairly weak, the existing data do provide some support for its use. In the cases reported, ECT was usually a last resort after failure of multiple pharmacologic and nonpharmacologic approaches, the impact of behavioral disturbance was severe, and reported benefits were usually of major clinical significance, Dr. Greenberg said, noting also that when addressed, global cognitive function was usually improved following ECT.

Thus, ECT is a reasonable option for dementia with severe agitation in cases after a careful diagnostic evaluation, including assessment for inciting/exacerbating causes, and after failure of behavioral and pharmacologic management.

In patients for whom ECT is deemed appropriate – and for whom proper consent is obtained – Dr. Greenberg recommended starting with titrated unilateral ultrabrief pulse stimulus (in nonemergent cases), and widening the treatment interval if the patients experience significant cognitive worsening.

ECT should be stopped when improvement plateaus, he said.

Also, consider an ECT taper to ensure stability of response and to allow for optimization of continuation pharmacotherapy, he said.

Continuation ECT can be considered if symptoms recur.

Environmental triggers of agitation also should be addressed, he said.

Dr. Petrides and Dr. Greenberg reported having no disclosures relevant to their presentations. Dr. Kellner reported receiving research support from the National Institute of Mental Health. He also reported serving as a paid contributor to UpToDate, a clinical decision support service and as a paid ECT course teacher at Northshore-LIJ Health System.

LOS ANGELES – Data continue to affirm the efficacy of electroconvulsive therapy, or ECT, for the treatment of major depression and other mood disorders, and numerous studies show that the benefits are particularly pronounced in older patients.

ECT experts at the annual meeting of the American Association for Geriatric Psychiatry shared some of these findings, along with newer data on optimal electrode placement, and an emerging indication for electroconvulsive therapy.

CORE age-related findings

Among adults aged 18-85 who were treated with ECT for unipolar depression in one study, for example, older patients responded better than did younger patients, Dr. Georgios Petrides said.

That study, the first from CORE (the Consortium for Research in Electroconvulsive Therapy), compared ECT with combination antidepressant/antipsychotic pharmacotherapy as a strategy for depression relapse prevention in 201 patients who had remitted after a course of bilateral ECT. Patients from five sites were randomized to receive either 10 continuation ECT treatments or 6 months of treatment with lithium and nortriptyline, said Dr. Petrides of the department of psychiatry at the Albert Einstein College of Medicine, New York, and director of ECT research at the Zucker Hillside Hospital, Glen Oaks, N.Y.

Both groups fared better than a historical placebo control group, but did not differ significantly from each other with respect to remission rates; 46% of patients in both groups remained in remission. Also, no differences were seen between the groups with respect to time to relapse among those who did not remain in remission (Arch. Gen. Psychiatry 2006;63:1337-44).

However, a later analysis of CORE data by age (18-45 years; 46-64 years; and 65 years and older) showed that the remission rates were significantly greater – at up to 90% – for the older patients, compared with the youngest group, Dr. Petrides said.

Of note, relapse rates were lower among patients with psychotic depression, compared with those with non-psychotic depression, and the age-based advantage also was apparent among those with psychotic depression, he said.

Age and electrode placement

A more recent CORE study looking at electrode placement for optimal efficacy and minimal cognitive impairment demonstrated age-based differences in outcomes as well.

In a randomized, controlled, double-blind trial, outcomes in 230 patients with major depression and a mean age of nearly 60 years were found to be similar with a novel bifrontal placement using 1.5 times the seizure threshold, a standard bitemporal placement using 1.5 times the seizure threshold, and with standard right unilateral placement using 6 times seizure threshold, Dr. Charles H. Kellner said.

All placements resulted in clinically and statistically significant improvements, with remission rates, based on strict remission criteria, of 61%, 64%, and 55% for the bifrontal, bitemporal, and right unilateral placements, respectively.

Using less strict criteria for response rather than remission, the rates for the three groups were 79%, 82%, and 73%%, respectively, noted Dr. Kellner, professor of psychiatry and director of the division of geriatric psychiatry at Mount Sinai School of Medicine, New York (Br. J. Psychiatry 2010;196:226-34).

A more rapid decline in symptoms was seen with bitemporal placement.

"So the take-home message there, is that if you have an urgently ill patient, either psychiatrically or medically, than bilateral electrode placement should be considered for them," said Dr. Kellner, who also is director of the ECT service at Mount Sinai Hospital.

Also of note, the remission rate was "remarkably greater" with right unilateral electrode placement in those over age 65 years, compared with younger patients (nearly 75% vs. about 40%-50%), and the remission rate was worse for bifrontal placement in those over age 65 years, compared with younger patient (about 45% vs. 65%).

"If this finding is replicated – and we’ve already partially replicated it (in the Prolonging Remission in Depressed Elderly [PRIDE] study)," he said. "This is good news that for geriatric patients, right unilateral ECT, the more benign form of the treatment, may be preferentially effective."

The finding that certain placements are better or worse in certain patients or age groups underscores the need for making all placements available, and choosing the one that is most appropriate for a patient’s individual circumstances, and the finding that all three electrode placements are effective underscores the argument that "ECT in contemporary practice is not a technical issue." He added, explaining that the data are clear about the effects of ECT, and that it is important to "fight to continue to get it accepted as a standard treatment – to move it up on the treatment algorithm so it is not considered a last resort for treatment."

Among the concerns about ECT that have impeded efforts to "move it up on the treatment algorithm" are those having to do with cognitive effects. Cognitive effects should be considered a tolerability issue rather than a safety issue when it comes to ECT, but regardless, in this study, almost no differences were found with respect to cognitive effects between the three placements studied, he said.

One exception was with reorientation.

"Patients wake up much more easily from right unilateral ECT," he said, noting that this also appears true in the PRIDE study, which is an ongoing evaluation of right unilateral ultrabrief pulse ECT.

Right unilateral ultrabrief pulse ECT

Preliminary data from the PRIDE trial also suggest that right unilateral ultrabrief pulse ECT is extremely effective in elderly patients: Of the first 152 patients from that study, 62% experienced remission, 11% did not, and 27% dropped out of the study.

The patients in that multicenter study have a mean age of 70 years and severe depression.

An interesting finding is that a small percentage of patients "get completely well with a short course of ECT," Dr. Kellner said.

Although most require the usual treatment course and some might require a longer treatment course, some remit very quickly. Thus, it is inappropriate to prescribe a fixed number of treatments in advance.

Also, as has been well documented in other ECT studies, outcomes with right unilateral ultrabrief pulse ECT improve with age.

"The older you get, the better ECT works," he said.

Remission rates were 62%-67% for those aged 70-79 years and 80 years or older, compared with 59% for those aged 60-69 years.

An emerging ECT indication: agitation

Among newer indications for ECT in older patients is agitation in dementia, according to Dr. Robert M. Greenberg.

Dementia is generally not a contraindication to ECT, and although most data on ECT in dementia involve patients with comorbid depression and/or psychosis, many case reports and two small case series suggest that it is effective for agitation alone in patients with dementia, said Dr. Greenberg, director of geriatric services and chief of geriatric psychiatry and ECT services at Lutheran Medical Center, Brooklyn, N.Y.

Behavioral and psychological symptoms, including agitation, occurs at some point in up to 90% of patients with dementia, and agitation and aggression occur in 60%-80% of patients with Alzheimer’s disease. These symptoms account for much of the functional impairment, caregiver burden, hospitalization, and health care costs in dementia patients, and treatment options are limited, he said.

Case reports over the past 2 decades suggest that anywhere from two to eight courses of ECT result in up to 12 months of improvement in symptoms, in some cases with monthly maintenance ECT or repeat courses.

In the largest retrospective case series published to date, 15 of 16 patients who underwent a mean of nine treatments – mostly administered bilaterally – experienced improvement in symptoms, Dr. Greenberg said.

Patients in that study included eight patients with Alzheimer’s disease. Three had mild dementia, eight had moderate-to-severe dementia, and five had severe dementia. Only two patients experienced severe postictal confusion (Am. J. Geriatr. Psychiatry 2012;20:61-72).

Although the evidence base for ECT for agitation in dementia remains fairly weak, the existing data do provide some support for its use. In the cases reported, ECT was usually a last resort after failure of multiple pharmacologic and nonpharmacologic approaches, the impact of behavioral disturbance was severe, and reported benefits were usually of major clinical significance, Dr. Greenberg said, noting also that when addressed, global cognitive function was usually improved following ECT.

Thus, ECT is a reasonable option for dementia with severe agitation in cases after a careful diagnostic evaluation, including assessment for inciting/exacerbating causes, and after failure of behavioral and pharmacologic management.

In patients for whom ECT is deemed appropriate – and for whom proper consent is obtained – Dr. Greenberg recommended starting with titrated unilateral ultrabrief pulse stimulus (in nonemergent cases), and widening the treatment interval if the patients experience significant cognitive worsening.

ECT should be stopped when improvement plateaus, he said.

Also, consider an ECT taper to ensure stability of response and to allow for optimization of continuation pharmacotherapy, he said.

Continuation ECT can be considered if symptoms recur.

Environmental triggers of agitation also should be addressed, he said.

Dr. Petrides and Dr. Greenberg reported having no disclosures relevant to their presentations. Dr. Kellner reported receiving research support from the National Institute of Mental Health. He also reported serving as a paid contributor to UpToDate, a clinical decision support service and as a paid ECT course teacher at Northshore-LIJ Health System.