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The Role of Antidepressant Medications During ECT: New Findings From OPT-ECT

Objective: In this report, we provide data from a multisite study of 339 patients with major depression that compared the efficacy of right unilateral (RUL) and bilateral (BL) electroconvulsive therapy (ECT) and examined the effect of concurrent antidepressant administration during ECT. Background: It has long been believed that the efficacy of ECT is independent of concomitant pharmacotherapy, and that combining ECT with antidepressant medications does not enhance therapeutic effects. This view was mainly supported by randomized trials in the 1960s that found no benefit from adding TCAs or MAOIs to ECT. This question deserves reevaluation because the population treated with ECT has become increasingly treatment resistant, and concomitant pharmacotherapy could be useful not only in enhancing efficacy but also as a strategy to protect against early relapse. Design/Methods: The Optimization of ECT study group conducted a controlled trial in which patients with major depression were randomized at 3 sites to treatment with high-dose RUL ECT (6 ST) or low-dose BL ECT (1.5 ST) and concurrent treatment with placebo, nortriptyline, or venlafaxine. Results: Preliminary analyses in 339 patients indicate no difference in efficacy between the 2 forms of ECT, with the differences in cognitive side effects favoring RUL ECT. Nortriptyline and venlafaxine have substantial advantages over placebo in short-term efficacy, both resulting in an approximately 15% increase in remission rates. Furthermore, relative to the placebo condition, cognitive side effects after the ECT course were reduced in the nortriptyline-treated patients and increased in those randomized to venlafaxine. There was no difference among the 3 pharmacological conditions in rates of serious adverse events or early dropout. Early dropout tended to be higher with BL than RUL ECT. Conclusions: These results demonstrate that high-dose RUL ECT and low-dose BL ECT are of equivalent efficacy in the treatment of depression. In addition, augmenting acute ECT with concurrent antidepressant treatment provides a significant increase in efficacy compared with patients receiving ECT alone. The findings were consistent across sites and support reconsideration of the role of antidepressants during the ECT course. In particular, enhancement of noradrenergic transmission during the ECT course (eg, with nortriptyline or other agents) may both improve ECT clinical outcome and reduce cognitive side effects.