ECT for Late-Life Depression: Older Age Linked to Rapid Response

Kenneth Bender

March 06, 2015

Older patients are among those most likely to achieve rapid remission of depressive symptoms with electroconvulsive therapy (ECT), new research suggests.

The new study, which examined demographic and clinical features of patients with different treatment response to ECT, revealed few differences between groups other than a statistically significantly higher mean age in those achieving rapid remission (65.3 years) than in the group with improved symptoms without remission (57.6 years) or in those without improvement (51.5 years).

"These findings are of paramount clinical importance, because practitioners might be reluctant to administer ECT to elderly depressed inpatients, whereas our results illustrate and confirm the favorable prognosis in older age," the investigators, led by Didi Rhebergen, MD, PhD, Department of Psychiatry, VU University Medical Center, Amsterdam, the Netherlands, write.

The study was published in the March issue of the American Journal of Geriatric Psychiatry.

Reluctant to Refer

Dr Rhebergen told Medscape Medical News that she undertook this study to gain more insight into an urgent problem.

"Since late-life depression often has a chronic course with debilitating effects on functioning and quality of life, insight into this matter is urgently needed," she said.

The investigators note that the presence of psychotic symptoms as well as shorter duration of depression have been associated with a favorable response to ECT. However, it is less clear whether age may be predictive.

Although some studies have linked older age with favorable outcomes, there are possible confounding factors, such as ECT administered earlier in the illness course of elderly patients who may not have tolerated antidepressant medications.

The cohort of 120 patients for the current study was drawn from two multicenter collaborative ECT clinical trials in Europe. The investigators distinguished patients by treatment response through a latent class growth analysis of course trajectory during 6 weeks of treatments. Depressive symptoms were measured with the 17-item Hamilton Rating Scale for Depression (HRSD). Remission was defined as an HRSD score of 8 or less.

Multivariate analysis was applied to such factors as age, sex, number of somatic illnesses, age at onset, number of depressive episodes, duration of the index episode, and presence of psychotic features.

In addition to statistically significantly higher median age in the rapidly responding group, the investigators found a slightly higher incidence of psychotic features in this group.

Controlling for the possible confounding factors of ECT being offered earlier in the course of illness to elderly patients, with corresponding lower rates of pharmacotherapy resistance and a shorter duration of the index episode, the investigators reported that "older age was still a predictor for favorable course trajectory."

Dr Rhebergen noted that although ECT has been shown to be the most effective biological treatment for depression, it remains underutilized, "especially in older-age patients," she said. "Clinicians are reluctant to refer a depressed patient for ECT, since they assume that ECT for late-life depression may be less effective."

Dr Rhebergen suggested that more research into the working mechanisms of ECT is needed.

"In addition, more insight into putative different subtypes of depressive disorders across age groups would provide insight into a favorable ECT response in elderly," she said.

"A Lifesaver"

Commenting on the findings for Medscape Medical News, Mark George, MD, distinguished professor of psychiatry, radiology, and neurosciences, Medical University of South Carolina, in Charleston, characterized the investigation as a quality study and described the latent class analysis methodology as "a sophisticated form of analyzing who will respond to ECT and response predictors."

The findings, said Dr George, confirm what many in the field have known for some time. "ECT in the elderly works rapidly and well, and is a lifesaver."

"This is hard for some clinicians to remember," he said, "as they are wrongly worried about cognition and risks of anesthesia with ECT. This study suggests that ECT should be used more commonly in elderly depression."

The authors and Dr George report no relevant financial relationships.

Am J Geriatr Psychiatry. 2015;23:274-282. Abstract

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