Relapse after abrupt discontinuation of maintenance electroconvulsive therapy during the COVID‐19 pandemic

Abstract

Objective Maintenance electroconvulsive therapy (M‐ECT) is considered an effective relapse prevention strategy in severe mood and psychotic disorders. How long M‐ECT should be continued, and what the outcome is after its discontinuation has not been adequately studied. In our tertiary psychiatric hospital, M‐ECT treatments were suspended at the start of the COVID‐19 pandemic. We aimed to determine the 6‐month relapse rate and time to relapse after abrupt discontinuation of M‐ECT and to assess the impact of patient and treatment characteristics on the risk of relapse. Methods Eighty‐one patients whose M‐ECT was discontinued abruptly were followed up prospectively for 6 months, or until relapse (i.e., hospital admission, restart of ECT, change of pharmacotherapy or suicide (attempt)). We used multivariable Cox proportional hazards models to assess the impact of patient and treatment characteristics on the risk of relapse. Results Thirty‐six patients (44.44%) relapsed within 6 months following abrupt discontinuation of M‐ECT. A greater number of previous acute ECT courses, a diagnosis of psychotic disorder (compared to major depressive disorder or bipolar disorder) and a shorter interval between M‐ECT treatments at the time of discontinuation were significantly associated with increased risk of relapse. Conclusion Almost half of the patients relapsed, similar to the relapse rate after a successful acute course of ECT. Patients with a shorter interval between M‐ECT treatments at the time of discontinuation seem to be at increased risk, as well as patients with a diagnosis of psychotic disorder, compared to patients with mood disorders.

An Online Survey About Electroconvulsive Therapy in Japan During the COVID-19 Pandemic: Comparison of Early and Recent Stages

“…In a follow-up study of 81 patients for whom maintenance ECT was abruptly discontinued because of the COVID-19 pandemic, 36 patients (44.44%) relapsed within a 6-month observation period. 18 In another study, the relapse rate also increased when the treatment was continued with a decreased frequency. 19 Patients at higher risk of relapse were those with diagnoses other than major depressive disorder (ie, bipolar disorder, schizophrenia, schizoaffective disorder) and those with shorter intervals between maintenance ECT treatments.…”

Provision of Electroconvulsive Therapy During the COVID-19 Pandemic

“… 23 Another study from Belgium following up on 81 patients whose maintenance ECT was abruptly discontinued because of the COVID-19 pandemic reported a 44.4% relapse rate in the 6 months after the discontinuation of ECT. 20 In a German university hospital, maintenance ECT was reduced in frequency or stopped in 86.8% of patients and remained unmodified in 13.2% of patients, based on factors like the persistence of marked residual symptoms, a lack of treatment alternatives, or at the patients' explicit request. Even though the patients without modification of maintenance ECT were clinically judged to be at the highest risk for relapse, patients with reduced frequency or discontinuation of maintenance ECT showed a significant clinical deterioration compared with patients without treatment modification.…”

“…Indeed, some studies have reported high rates of relapse when maintenance ECT was abruptly discontinued. 20,22,23 In cases where the most severely ill patients were able to stay on maintenance ECT, relapse rates were higher in the less severely ill patients whose maintenance ECT was suspended. 22 Several commentaries have called for the continued provision of ECT during the pandemic, arguing that ECT is an essential rather than an elective procedure.…”

“…Indeed, some studies have reported high rates of relapse when maintenance ECT was abruptly discontinued. 20 , 22 , 23 In cases where the most severely ill patients were able to stay on maintenance ECT, relapse rates were higher in the less severely ill patients whose maintenance ECT was suspended. 22 …”

Electroconvulsive Therapy: Stayin’ Alive, Stayin’ Well

“…In the current issue of Acta, there are three new publications with data about staying well, or not, in the 6-to 12-month period after successful index courses of electroconvulsive therapy (ECT). [1][2][3] show no difference in 12-month relapse rates between patients treated with right unilateral versus bilateral ECT in a secondary analysis of data from the EFFECT-Dep trial; Lambrichts et al and Methfessel et al show that withholding maintenance ECT, in both cases an "experiment of nature" imposed by the COVID epidemic, leads to clinical deterioration and relapse in a substantial number of previously stable patients. All three articles focus our attention on the crucial clinical issue of how best to keep patients with serious mood and psychotic disorders well for the long term.…”