Elsevier

Biological Psychiatry

Volume 55, Issue 3, 1 February 2004, Pages 301-312
Biological Psychiatry

Original article
Effectiveness of electroconvulsive therapy in community settings

https://doi.org/10.1016/j.biopsych.2003.09.015Get rights and content

Abstract

Background

Clinical trials indicate that electroconvulsive therapy (ECT) is the most effective treatment for major depression, but its effectiveness in community settings has not been examined.

Methods

In a prospective, naturalistic study involving 347 patients at seven hospitals, clinical outcomes immediately after ECT and over a 24-week follow-up period were examined in relation to patient characteristics and treatment variables.

Results

The sites differed markedly in patient features and ECT administration but did not differ in clinical outcomes. In contrast to the 70%–90% remission rates expected with ECT, remission rates, depending on criteria, were 30.3%–46.7%. Longer episode duration, comorbid personality disorder, and schizoaffective disorder were associated with poorer outcome. Among remitters, the relapse rate during follow-up was 64.3%. Relapse was more frequent in patients with psychotic depression or comorbid Axis I or Axis II disorders. Only 23.4% of ECT nonremitters had sustained remission during follow-up.

Conclusions

The remission rate with ECT in community settings is substantially less than that in clinical trials. Providers frequently end the ECT course with the view that patients have benefited fully, yet formal assessment shows significant residual symptoms. Patients who do not remit with ECT have a poor prognosis; this underscores the need to achieve maximal improvement with this modality.

Section snippets

Study sites and study participation

The study was conducted at seven hospitals in the New York City metropolitan area. The sites included two private psychiatric hospitals, three community general hospitals, and two hospitals at university medical centers. A clinical outcomes evaluator was assigned to each hospital and collected all the research information. These evaluators conducted clinical and neuropsychological research assessments and obtained data on clinical and treatment history. They had no involvement or impact on the

Results

Of the 751 patients scheduled to receive ECT at the 7 sites, 398 (53.0%) consented to study participation (Figure 1). Of the 353 patients who did not enter the study, 128 (36.3%) patients met one or more exclusion criteria, with a psychiatric diagnosis other than a depressive disorder being the most common (n = 46, 13.0%). Of the remaining 225 patients who might have been eligible, the most common reasons for nonparticipation were insufficient time before the first ECT treatment to conduct the

Discussion

We have provided evidence that ECT is substantially less effective in community practice than previously assumed from the results of clinical trials. Whereas the rate of remission in clinical trials is typically reported to be on the order of 70%–90% American Psychiatric Association, 2001, Petrides et al., 2001, Sackeim et al., 1993, Sackeim et al., 2000, the intent-to-treat remission rates from a large cohort of adults treated with ECT in community facilities were in the range of 30%–47%. The

Acknowledgements

This work was supported in part by Grants R01 MH59069 (JP, MO, HAS), R01 MH35636 (HAS, JP), and R01 MH61609 (HAS, JP) from the National Institute of Mental Health.

We thank the electroconvulsive therapy directors at the participating institutions, as well as the medical staffs, for their assistance in conducting this study.

References (63)

  • A.T. Beck et al.

    Beck Depression Inventory Manual

    (1996)
  • N. Casacalenda et al.

    Remission in major depressive disorderA comparison of pharmacotherapy, psychotherapy, and control conditions

    Am J Psychiatry

    (2002)
  • C. DeBattista et al.

    Is electroconvulsive therapy effective for the depressed patient with comorbid borderline personality disorder?

    J ECT

    (2001)
  • M.R. DiMatteo et al.

    Depression is a risk factor for noncompliance with medical treatmentMeta-analysis of the effects of anxiety and depression on patient adherence

    Arch Intern Med

    (2000)
  • L.B. Dixon et al.

    Conventional antipsychotic medications for schizophrenia

    Schizophr Bull

    (1995)
  • A. Farah et al.

    Electroconvulsive therapy stimulus dosingA survey of contemporary practices

    Convuls Ther

    (1993)
  • M.B. First et al.

    Structured Clinical Interview for Axis I DSM-IV Disorders—Patient Edition (with Psychotic Screen) (SCID-I/P)

    (1996)
  • M.B. First et al.

    Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II)

    (1996)
  • H.W. Folkerts et al.

    Electroconvulsive therapy vs. paroxetine in treatment-resistant depression—a randomized study

    Acta Psychiatr Scand

    (1997)
  • E. Frank et al.

    Conceptualization and rationale for consensus definitions of terms in major depressive disorder. Remission, recovery, relapse, and recurrence

    Arch Gen Psychiatry

    (1991)
  • B. Gangadhar et al.

    Comparison of electroconvulsive therapy with imipramine in endogenous depressionA double blind study

    Br J Psychiatry

    (1982)
  • L. Grunhaus et al.

    Coadministration of melatonin and fluoxetine does not improve the 3-month outcome following ECT

    J ECT

    (2001)
  • G. Halliday et al.

    Training to administer electroconvulsive therapyA survey of attitudes and experiences

    Aust N Z J Psychiatry

    (1995)
  • M. Hamilton

    Development of a rating scale for primary depressive illness

    Br J Soc Clin Psychol

    (1967)
  • R.B. Haynes et al.

    Helping patients follow prescribed treatmentClinical applications

    JAMA

    (2002)
  • R.C. Hermann et al.

    Variation in ECT use in the United States

    Am J Psychiatry

    (1995)
  • M.E. Hewitt et al.

    Ensuring Quality Cancer Care

    (1999)
  • J.W. Hoekstra et al.

    Improving the care of patients with non-ST-elevation acute coronary syndromes in the emergency departmentThe CRUSADE initiative

    Acad Emerg Med

    (2002)
  • A.B. Hollingshead

    Four Factor Index of Social Status

    (1975)
  • P. Janicak et al.

    Efficacy of ECTA meta-analysis

    Am J Psychiatry

    (1985)
  • L.B. Kalinowsky et al.

    Shock Treatments and Other Somatic Procedures in Psychiatry

    (1946)
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