AMSTERDAM, The Netherlands – The latest results of the “Prolonged Relief in Elderly Depressed Patients” (PRIDE) study show that electroconvulsive therapy (ECT) with right unilateral electrode placement and ultrashort pulse stimulation three times a week for elderly patients with monophasic depression is ideal for achieving a rapid response. The study was presented at the 28th Annual Meeting of the European Society of Neuropsychopharmacology (ECNP).
One of the preferred options for geriatric depression
“ECT remains the recommended treatment for depressed older patients; it remains quite safe even for those with physical illness, or who have difficulty tolerating other treatments including antidepressants.” So says Dr. Charles Kellner, professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York.
“We tend to choose individualized treatments based on the urgency of the condition, yet we have to admit that ECT does have a higher response rate for older patients. It can be argued that ECT is a powerful and heavy weapon for treating depression, and ECT using a right single electrode and ultrashort pulse stimulation can induce convulsions through very low power, which is a major advantage.”
According to an early report on the PRIED study in 2013, a total of about 240 patients were enrolled in the study, 173 of whom completed the first phase of the PRIED study.
At baseline, patients had a mean age of 70 years and a mean score of 31 on the Hamilton Rating Scale for Depression (HRSD24), which contains 24 items, suggesting considerable depression. Of these, only 11% of subjects had psychotic symptoms, a low percentage in depression studies.
Treatment response in the study was defined as a 50% reduction in HRSD24 score; remission was defined as two consecutive HRSD24 scores ≤10. After 3 weekly ultrashort pulse ECT + venlafaxine 225 mg/d, 148 patients achieved symptom remission as follows.
Validity
At the end of the first phase, the study reported a 62% symptom remission rate, with approximately 10% of patients not in remission and 28% shedding symptoms during treatment. At this point, the subjects’ HRSD24 scores dropped from 31 at baseline to 6, “a considerable margin that suggests great improvement.”
In fact, for those patients who did not remit and shed, most of them gained from ECT to varying degrees, even if they did not meet the strict response or remission criteria.
Rapid onset of action
After the first treatment, 10 percent of patients achieved a 50 percent HRSD24 score reduction. “It is important to remember that the first treatment was used with ultra-low power and was aimed at finding the patient’s convulsive seizure threshold.” Dr. Kellner noted.
After the second treatment, 28% of patients achieved a 50% reduction in HRSD24; after the third treatment, 40% of patients achieved a 50% reduction in HRSD24.
Dr. Kellner added that 8 percent of subjects achieved remission after two treatments, a figure that rose to 18 percent after three treatments. “These patients were chronically ill, but also showed significant improvement after 1 week of treatment.”
Consistent with expectations, patients with psychotic symptoms responded better to ECT treatment compared to patients in the cohort without psychotic symptoms. Previously, similar results have been extensively validated.
In the PRIDE study, the average number of treatments needed to generate a response was 7.3, but 20% of patients achieved remission at <4 ECT treatments, and three-quarters remitted within three weeks. Of course, some patients also achieved remission after a much longer period of time.
“You don’t tell patients definitively how many treatments they need at the beginning of treatment,” Dr. Kellner emphasized, “Patients need to stay on treatment until they are in good condition, and also some patients need a longer course of treatment than others.”
Dr. Kellner reminded attendees that suicidal ideation is one of the most serious symptoms in patients with mood disorders. At baseline, suicidal ideation was more pronounced in more than 22 percent of patients based on scores on the third HRSD24 item. At the end of the study, close to 85% of patients scored 0 on the same entry, suggesting that most patients no longer had residual suicidal tendencies.
“In conclusion, right unilateral ECT is a viable treatment for elderly depressed patients; the therapy has a rapid onset of action, including efficacy against suicidal ideation.”
“Furthermore, patients can rapidly reorient to time, environment, and people after such ECT treatment, suggesting that the treatment is quite well tolerated cognitively.”
Specific cognitive data from the Phase 1 study and efficacy data from the Phase 2 study will be published soon.
Up and down and seeking
Commenting on the use of ECT in the general population, particularly in the elderly, Dr. William Nolan, co-chair of the conference section and professor emeritus at the University of Groningen, said that more than 70 years after the discovery of ECT, it is surprising that people are still tirelessly exploring better ways to implement it: bilateral or unilateral, which current to use, how long the stimulation should last, whether ECT should continue as maintenance therapy or be replaced by antidepressants, behavioral therapy or a combination of both: the latter seems to maintain remission for a longer period of time than antidepressants alone.
However, one of the biggest obstacles to the effective use of ECT remains its lingering stigma. In the Netherlands in the 1970s, ECT had a notorious reputation, with only about 40 patients receiving ECT treatment each year. Today, patients and professionals are becoming aware of how effective ECT is and how quickly it works, and the treatment is becoming more widely used.
“Of course, ECT is not suitable for every patient. Many forms of psychological and pharmacological treatment are easier to implement, and ketamine and intracranial stimulation are also quite fast-acting. However, older adults are more susceptible to adverse reactions to antidepressants, and for this reason, there is a strong case for using ECT for the older patient population.” Dr. Nolan stated.
“The response to ECT is very rapid, which is what we would like to see: if older patients are chronically depressed and inactive, the risk of somatic complications is also elevated.”
28th European College of Neuropsychopharmacology (ECNP) Congress: Abstract S.05.04. Presented August 30, 2015.
Credit: PamHarrisonet al. PRIDE Continues to Support ECT in Depressed Elderly. medscape. august 30, 2015.