ORIGINAL STUDY
Improving Relapse Prevention After Successful Electroconvulsive Therapy For Patients With Severe Depression Completed Audit Cycle Involving 102 Full Electroconvulsive Therapy Courses in West Sussex, United Kingdom Leonard Atiku, MBChB, MRCPsych,* Caroline Gorst-Unsworth, MBChB, MRCPsych,* Barkath Ulla Khan, MBBS,* Fuad Huq, BMBS,† and Jackie Gordon, MAMBBChir, MRCPsych* Objectives: The aim of this study was to determine whether current guidance or consensus regarding continuation pharmacotherapy after successful electroconvulsive therapy (ECT) was being followed by referring clinicians in West Sussex, United Kingdom. Methods: A complete audit cycle examining psychotropic medication after successful ECT for patients with severe depression was performed. Clinical and ECT records (electronic and paper) were reviewed, and relapse rates in the 4 commonly prescribed psychotropic medication groups were compared. Results: The pattern of relapse in the 4 groups was similar for both audits 1 and 2. Taking the 102 patients as a whole, the lowest relapse rates were recorded for patients taking a combination of an antidepressant and lithium (16% relapsed within 6 months of successful ECT). Patients taking a combination of antipsychotic and antidepressants fared the worst with 75% relapse rate. This was followed by those taking a combination of antidepressant and a mood stabilizer (other than lithium) (69%). Patients taking antidepressant(s) only were associated with a relapse rate of 60%. Audit 2 demonstrated that clinicians did not change their prescribing practices for their patients after successful ECT despite the efforts made in widely disseminating the results of audit 1. In particular, there was no increase in the use of lithium. Conclusions: Not all psychotropic medication prescribing for patients receiving ECT for depression followed available and current guidance or consensus. More needs to be done to understand the reasons for the reluctance to use lithium if relapse rates after ECT are to improve. Key Words: continuation, pharmacotherapy, lithium (J ECT 2015;31: 34–36)
W
orthing electroconvulsive therapy (ECT) clinic takes referrals from all over the county of West Sussex in the United Kingdom, and once remission is achieved, the aftercare of patients is handed back to the referring team. This audit was instigated by the observation that after successful ECT for depression, a substantial number of patients were returning for further treatments within a few months. The objective was to determine whether current guidance or consensus regarding continuation pharmacotherapy after ECT was being followed by referring clinicians in West From the *Sussex Partnership NHS Foundation Trust, Worthing, West Sussex; and †United Linconshire Hospitals NHS Trust, Grantham and District Hospital, Grantham, Linconshire, UK. Received for publication January 21, 2014; accepted June 5, 2014. Reprints: Caroline Gorst-Unsworth, MBChB, MRCPsych, Meadowfield Hospital, Swandean, Arundel Rd, Worthing, West Sussex, United Kingdom, BN13 3EP (e‐mail: [email protected]). The authors have no conflicts of interest or financial disclosures to report. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000164
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Sussex. We describe a completed audit cycle and suggest some possible explanations for the very limited change in practice. Despite being an effective treatment for depression, ECT is associated with high relapse rates. Relapse has been reported between 25% and 60%, even with continuation antidepressant pharmacotherapy. Individual studies and meta-analyses have suggested that relapse rates can be reduced by using imipramine, nortriptyline, the combination of lithium and nortriptyline, the combination of venlafaxine and lithium, or continuation ECT.1–6 However, there is, as yet, no definitive answer as to which specific combinations have the best results in practice. Guidelines on follow-up treatment after ECT do exist but tend to be somewhat flexible, and there is no clear consensus on specific treatment regimes. The Royal College of Psychiatrists’ current ECT handbook states that “relapse rates are high after remission is achieved in depression, and antidepressants reduce the risk of relapse by about 70%” and that “the combination of lithium/antidepressant may reduce the risk of relapse after ECT.”7 The National Institute for Health and Clinical Excellence guidance on ECT for the United Kingdom states that “combination treatment with lithium and nortriptyline may be effective in reducing the likelihood of relapse following successful treatment with ECT.”8 The National Institute for Health and Clinical Excellence guidance on depression states that “augmentation for severe depression can involve lithium, antipsychotic, or another antidepressant,” but it specifically instructs, “do not routinely augment with benzodiazepines, buspirone, carbamazepine, lamotrigine, valproate, pindolol, or thyroid hormones.”9 Locally, the West Sussex policy on ECT takes into account the available evidence and includes general guidance on ensuring that after ECT, the treatment plan “considers robust maintenance medication with augmentation regimes to prevent relapse.”
MATERIALS AND METHODS Electroconvulsive therapy clinic records were used to identify all patients who received ECT at the Worthing unit from March 2007 to January 2009. From a total of 71 courses of ECT, 51 cases were included in the audit. Only cases with a diagnosis of “depression” were examined. This definition was taken from clinical notes and included the International Statistical Classification of Diseases, 10th Revision categories F30 to F39. This includes unipolar depression and depressive episode in bipolar affective disorder. Of the 20 cases not examined, 10 were excluded because the case notes could not be located as during this period, paper records were still being kept, and notes were dispersed around a wide geographical area. Other reasons for exclusion included a diagnosis outside the specified International Statistical Classification of Diseases, 10th Revision categories Journal of ECT • Volume 31, Number 1, March 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Journal of ECT • Volume 31, Number 1, March 2015
Improving Relapse Prevention After Successful ECT
(3 cases of schizoaffective disorder, 4 cases of dysthymia in context of long-standing personality disorder). Two patients died before the end of the data collection period, and one was undergoing maintenance ECT. Data collected included the psychotropic medications at the time of completion of ECT and any evidence of “relapse” in the notes within the next 6 months. The definition of relapse was taken as a reemergence of depressive symptoms sufficient to require either a major medication review or readmission to hospital. Minor medication changes in response to minor symptoms did not constitute relapse (eg, addition of hypnotic). Four patient groups were identified based on psychotropic medication taken during and after ECT. They included the following: A. Those taking antidepressant(s) only. B. Those taking a combination of antidepressant(s) and antipsychotic(s). C. Those taking a combination of antidepressant(s) and a mood stabilizer (other than lithium). D. Those taking a combination of antidepressant(s) and lithium.
After the first audit, results were disseminated to all referring clinicians in a number of different ways as follows: presentation at clinical audit meetings, e-mail communication direct to all referring consultants, and specific seminars to update senior psychiatrists on all aspects of ECT. After dissemination of results and recommendations for change, the audit process was repeated on a further 51 patients who received ECT between September 2009 and October 2010. Of 59 courses identified during this period, all case notes were located, as electronic records were in operation by this time. However, 8 were excluded (2 cases of schizoaffective disorder, 4 cases of dysthymia in context of long-standing personality disorder or organic brain disorder, 1 deceased, and 1 undergoing maintenance ECT).
RESULTS Table 1 shows the demographic characteristics of patients. The second audit included proportionately less males than the first audit, but this was not statistically significant ( 2 with Yates correction 3.2, P ≥ 0.1). All other demographic details were similar in both audit samples. Table 2 shows the percentage relapse in each group during audits 1 and 2 and in the pooled groups. In terms of numbers TABLE 1. Demographic Characteristics of Patients Demographics Sex Male Female Age, y Younger than 65 Older than 65 Ethnicity White British Irish White European Arabic Other
Audit 1
Audit 2
17 34
10 41
13 38
25 26
48 02 01 00 00
49 01 00 01 00
TABLE 2. Percentage Relapse According to Medication Group Medication Group
Audit 1
Audit 2
Pooled Results
A B C D Percentage relapse
60% (n = 10) 80% (n = 25) 80% (n = 5) 18% (n = 11) 59.5%
60% (n = 5) 70% (n = 20) 58% (n = 12) 14% (n = 14) 51%
60% (n = 15) 75% (n = 45) 69% (n = 17) 16% (n = 25) 55.25%
of patients in each medication group, there was no statistically significant difference between audits 1 and 2 ( 2 = 5.46, P ≥ 0.2). In particular, there was very little increase in lithium prescribing. Taking the pooled results (n = 102), there was significant heterogeneity of relapse rate between the 4 medication groups ( 2 = 10.31, df = 3, P < 0.05), and group D (with lithium added) shows a statistically significant lower rate of relapse, compared with the other groups of medication (z = 8.35, P < 0.0001).
DISCUSSION This audit highlighted that in West Sussex, United Kingdom, not all medication regimes after successful ECT followed guidelines and available evidence. The combined results from both audits show a clear difference in relapse rate between medication regimes containing lithium and those not containing lithium. In particular, adding other mood stabilizers or antipsychotics was associated with high relapse rates after ECT in our sample (69% and 75%, respectively), which represented a worse outcome than using antidepressants alone. It is important to note that this is an audit and not a comparative study. Patients were not randomized. The authors were not blind to the medication regime when collecting data about relapse, and because of an element of judgement used to define relapse, this could be a source of bias. There are many confounding variables such as age, severity of illness, diagnosis, doses of medication used, other nonpharmacological interventions offered, frequency of follow-up appointments, and so on. However, it does represent real-life clinical practice, and combined results of both audits found a significantly reduced relapse rate when lithium was added, in comparison to all other medication combinations. It is unclear why the relapse rate with lithium in this audit was lower than published studies. Perhaps these patients were managed by particularly attentive clinicians because lithium use was relatively infrequent overall.
FIGURE 1. Graph comparing pooled percentage relapse between the groups.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ectjournal.com
35
Journal of ECT • Volume 31, Number 1, March 2015
Atiku et al
The question remains—why, when evidence and guidelines suggest adding lithium is useful after ECT, and local audits confirm this, are clinicians failing to change practice? In the current climate of cost-efficiency drives and focus on clinical effectiveness, clinicians seem to favor newer and expensive drug regimes over evidence-based but cheaper options. The audit suggests that the use of lithium could save on readmissions and repeat ECT courses. Some possible reasons for the reluctance to use lithium could include inexperience with its prescription and management, fear of adverse effects, fear of risks/complications, belief that “newer” drugs are better and that lithium is “old fashioned,” or patient refusal/reluctance to take lithium. To test out some of these assumptions, a questionnaire was sent out to all referrers to the ECT clinic. A total of 14 (53.8%) of 26 yielded a response. Nine (64%) of the 14 responders said that they would consider using lithium augmentation regimes after ECT. Most common reasons given in favor of lithium were “most effective with best evidence base” and “personal experience of it being effective.” Reasons given by those who did not use lithium augmentation included “adverse effect profile and toxicity,” “inconvenience of blood monitoring,” “new ways of working (resulting in lack of continuity in follow-up),” and “patient choice.” It is known that the monitoring of lithium needs improving. This was the subject of 1 of the Prescribing Observatory for Mental Health national audits in the United Kingdom.10 Readmission to hospital for further ECT is expensive; therefore it may be cost-effective to put additional resource into the improved take-up of lithium prescribing. Possible solutions include more regular feedback and updates to senior colleagues about post-ECT treatments, inbuilt reminders/prompts to clinicians once a patient has finished ECT, nurse-led lithium clinics for monitoring of lithium, or even ECT clinic staff becoming involved in medication decisions and postECT monitoring of medication. Effecting change is not easy and requires sustained effort. The ECT clinic in West Sussex is currently piloting various
36
www.ectjournal.com
methods to increase the prescribing of lithium and reduce relapse rate after successful ECT. REFERENCES 1. Sackeim HA, Hasket RF, Mulsant BH, et al. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy—a randomized controlled trial. JAMA. 2001;285:1299–1307. 2. Prudic J, Haskett RF, McCall WV, et al. Pharmacological strategies in the prevention of relapse after electroconvulsive therapy. J ECT. 2013;29:3–12. 3. Jelovac A, Kolshus E, McLoughlin DM. Relapse following successful electroconvulsive therapy for major depression. A meta-analysis. Neuropharmacology. 2013;38:2467–2474. 4. Von Schweder J. Post ECT pharmacotherapy: an update. Eur Psychiatry. 2009;24:74. 5. Van den Broek W, Birkenhager T, Mulder P, et al. Imipramine is effective in preventing relapse in electroconvulsive therapy-responsive depressed inpatients with prior pharmacotherapy treatment failure: a randomized, placebo-controlled trial. J Clin Psychiatry. 2006;76:263–268. 6. Kellner CH, Knapp RG, Petrides G, et al. Continuation electroconvulsive therapy versus pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry. 2006;63:1337–1344. 7. Waite J, Easton A, eds. The ECT Handbook. 3rd ed. Royal College of Psychiatrists, College Report CR176. London UK: RCPsych publications; 2012. 8. Guidance on the Use of Electroconvulsive Therapy. NICE Technology Appraisal Guidance 59; (Nov 2005). Available at: http://www.nice.org.uk/nicemedia/pdf/59ectfullguidance.pdf. 9. Depression: The Treatment and Management of Depression in Adults. NICE Clinical Guideline 90; (Oct 2009). Available at: http://www.nice.org.uk/nicemedia/live/12329/45888/45888.pdf. 10. Prescribing Observatory for Mental Health (2012). Topic 7c. Monitoring of Patients Prescribed Lithium: Supplementary Report. POMH CCQI 118 (data on file).
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Improving Relapse Prevention After Successful Electroconvulsive Therapy For Patients With Severe Depression Completed Audit Cycle Involving 102 Full Electroconvulsive Therapy Courses in West Sussex, United Kingdom Leonard Atiku, MBChB, MRCPsych,* Caroline Gorst-Unsworth, MBChB, MRCPsych,* Barkath Ulla Khan, MBBS,* Fuad Huq, BMBS,† and Jackie Gordon, MAMBBChir, MRCPsych* Objectives: The aim of this study was to determine whether current guidance or consensus regarding continuation pharmacotherapy after successful electroconvulsive therapy (ECT) was being followed by referring clinicians in West Sussex, United Kingdom. Methods: A complete audit cycle examining psychotropic medication after successful ECT for patients with severe depression was performed. Clinical and ECT records (electronic and paper) were reviewed, and relapse rates in the 4 commonly prescribed psychotropic medication groups were compared. Results: The pattern of relapse in the 4 groups was similar for both audits 1 and 2. Taking the 102 patients as a whole, the lowest relapse rates were recorded for patients taking a combination of an antidepressant and lithium (16% relapsed within 6 months of successful ECT). Patients taking a combination of antipsychotic and antidepressants fared the worst with 75% relapse rate. This was followed by those taking a combination of antidepressant and a mood stabilizer (other than lithium) (69%). Patients taking antidepressant(s) only were associated with a relapse rate of 60%. Audit 2 demonstrated that clinicians did not change their prescribing practices for their patients after successful ECT despite the efforts made in widely disseminating the results of audit 1. In particular, there was no increase in the use of lithium. Conclusions: Not all psychotropic medication prescribing for patients receiving ECT for depression followed available and current guidance or consensus. More needs to be done to understand the reasons for the reluctance to use lithium if relapse rates after ECT are to improve. Key Words: continuation, pharmacotherapy, lithium (J ECT 2015;31: 34–36)
W
orthing electroconvulsive therapy (ECT) clinic takes referrals from all over the county of West Sussex in the United Kingdom, and once remission is achieved, the aftercare of patients is handed back to the referring team. This audit was instigated by the observation that after successful ECT for depression, a substantial number of patients were returning for further treatments within a few months. The objective was to determine whether current guidance or consensus regarding continuation pharmacotherapy after ECT was being followed by referring clinicians in West From the *Sussex Partnership NHS Foundation Trust, Worthing, West Sussex; and †United Linconshire Hospitals NHS Trust, Grantham and District Hospital, Grantham, Linconshire, UK. Received for publication January 21, 2014; accepted June 5, 2014. Reprints: Caroline Gorst-Unsworth, MBChB, MRCPsych, Meadowfield Hospital, Swandean, Arundel Rd, Worthing, West Sussex, United Kingdom, BN13 3EP (e‐mail: [email protected]). The authors have no conflicts of interest or financial disclosures to report. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000164
34
www.ectjournal.com
Sussex. We describe a completed audit cycle and suggest some possible explanations for the very limited change in practice. Despite being an effective treatment for depression, ECT is associated with high relapse rates. Relapse has been reported between 25% and 60%, even with continuation antidepressant pharmacotherapy. Individual studies and meta-analyses have suggested that relapse rates can be reduced by using imipramine, nortriptyline, the combination of lithium and nortriptyline, the combination of venlafaxine and lithium, or continuation ECT.1–6 However, there is, as yet, no definitive answer as to which specific combinations have the best results in practice. Guidelines on follow-up treatment after ECT do exist but tend to be somewhat flexible, and there is no clear consensus on specific treatment regimes. The Royal College of Psychiatrists’ current ECT handbook states that “relapse rates are high after remission is achieved in depression, and antidepressants reduce the risk of relapse by about 70%” and that “the combination of lithium/antidepressant may reduce the risk of relapse after ECT.”7 The National Institute for Health and Clinical Excellence guidance on ECT for the United Kingdom states that “combination treatment with lithium and nortriptyline may be effective in reducing the likelihood of relapse following successful treatment with ECT.”8 The National Institute for Health and Clinical Excellence guidance on depression states that “augmentation for severe depression can involve lithium, antipsychotic, or another antidepressant,” but it specifically instructs, “do not routinely augment with benzodiazepines, buspirone, carbamazepine, lamotrigine, valproate, pindolol, or thyroid hormones.”9 Locally, the West Sussex policy on ECT takes into account the available evidence and includes general guidance on ensuring that after ECT, the treatment plan “considers robust maintenance medication with augmentation regimes to prevent relapse.”
MATERIALS AND METHODS Electroconvulsive therapy clinic records were used to identify all patients who received ECT at the Worthing unit from March 2007 to January 2009. From a total of 71 courses of ECT, 51 cases were included in the audit. Only cases with a diagnosis of “depression” were examined. This definition was taken from clinical notes and included the International Statistical Classification of Diseases, 10th Revision categories F30 to F39. This includes unipolar depression and depressive episode in bipolar affective disorder. Of the 20 cases not examined, 10 were excluded because the case notes could not be located as during this period, paper records were still being kept, and notes were dispersed around a wide geographical area. Other reasons for exclusion included a diagnosis outside the specified International Statistical Classification of Diseases, 10th Revision categories Journal of ECT • Volume 31, Number 1, March 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Journal of ECT • Volume 31, Number 1, March 2015
Improving Relapse Prevention After Successful ECT
(3 cases of schizoaffective disorder, 4 cases of dysthymia in context of long-standing personality disorder). Two patients died before the end of the data collection period, and one was undergoing maintenance ECT. Data collected included the psychotropic medications at the time of completion of ECT and any evidence of “relapse” in the notes within the next 6 months. The definition of relapse was taken as a reemergence of depressive symptoms sufficient to require either a major medication review or readmission to hospital. Minor medication changes in response to minor symptoms did not constitute relapse (eg, addition of hypnotic). Four patient groups were identified based on psychotropic medication taken during and after ECT. They included the following: A. Those taking antidepressant(s) only. B. Those taking a combination of antidepressant(s) and antipsychotic(s). C. Those taking a combination of antidepressant(s) and a mood stabilizer (other than lithium). D. Those taking a combination of antidepressant(s) and lithium.
After the first audit, results were disseminated to all referring clinicians in a number of different ways as follows: presentation at clinical audit meetings, e-mail communication direct to all referring consultants, and specific seminars to update senior psychiatrists on all aspects of ECT. After dissemination of results and recommendations for change, the audit process was repeated on a further 51 patients who received ECT between September 2009 and October 2010. Of 59 courses identified during this period, all case notes were located, as electronic records were in operation by this time. However, 8 were excluded (2 cases of schizoaffective disorder, 4 cases of dysthymia in context of long-standing personality disorder or organic brain disorder, 1 deceased, and 1 undergoing maintenance ECT).
RESULTS Table 1 shows the demographic characteristics of patients. The second audit included proportionately less males than the first audit, but this was not statistically significant ( 2 with Yates correction 3.2, P ≥ 0.1). All other demographic details were similar in both audit samples. Table 2 shows the percentage relapse in each group during audits 1 and 2 and in the pooled groups. In terms of numbers TABLE 1. Demographic Characteristics of Patients Demographics Sex Male Female Age, y Younger than 65 Older than 65 Ethnicity White British Irish White European Arabic Other
Audit 1
Audit 2
17 34
10 41
13 38
25 26
48 02 01 00 00
49 01 00 01 00
TABLE 2. Percentage Relapse According to Medication Group Medication Group
Audit 1
Audit 2
Pooled Results
A B C D Percentage relapse
60% (n = 10) 80% (n = 25) 80% (n = 5) 18% (n = 11) 59.5%
60% (n = 5) 70% (n = 20) 58% (n = 12) 14% (n = 14) 51%
60% (n = 15) 75% (n = 45) 69% (n = 17) 16% (n = 25) 55.25%
of patients in each medication group, there was no statistically significant difference between audits 1 and 2 ( 2 = 5.46, P ≥ 0.2). In particular, there was very little increase in lithium prescribing. Taking the pooled results (n = 102), there was significant heterogeneity of relapse rate between the 4 medication groups ( 2 = 10.31, df = 3, P < 0.05), and group D (with lithium added) shows a statistically significant lower rate of relapse, compared with the other groups of medication (z = 8.35, P < 0.0001).
DISCUSSION This audit highlighted that in West Sussex, United Kingdom, not all medication regimes after successful ECT followed guidelines and available evidence. The combined results from both audits show a clear difference in relapse rate between medication regimes containing lithium and those not containing lithium. In particular, adding other mood stabilizers or antipsychotics was associated with high relapse rates after ECT in our sample (69% and 75%, respectively), which represented a worse outcome than using antidepressants alone. It is important to note that this is an audit and not a comparative study. Patients were not randomized. The authors were not blind to the medication regime when collecting data about relapse, and because of an element of judgement used to define relapse, this could be a source of bias. There are many confounding variables such as age, severity of illness, diagnosis, doses of medication used, other nonpharmacological interventions offered, frequency of follow-up appointments, and so on. However, it does represent real-life clinical practice, and combined results of both audits found a significantly reduced relapse rate when lithium was added, in comparison to all other medication combinations. It is unclear why the relapse rate with lithium in this audit was lower than published studies. Perhaps these patients were managed by particularly attentive clinicians because lithium use was relatively infrequent overall.
FIGURE 1. Graph comparing pooled percentage relapse between the groups.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ectjournal.com
35
Journal of ECT • Volume 31, Number 1, March 2015
Atiku et al
The question remains—why, when evidence and guidelines suggest adding lithium is useful after ECT, and local audits confirm this, are clinicians failing to change practice? In the current climate of cost-efficiency drives and focus on clinical effectiveness, clinicians seem to favor newer and expensive drug regimes over evidence-based but cheaper options. The audit suggests that the use of lithium could save on readmissions and repeat ECT courses. Some possible reasons for the reluctance to use lithium could include inexperience with its prescription and management, fear of adverse effects, fear of risks/complications, belief that “newer” drugs are better and that lithium is “old fashioned,” or patient refusal/reluctance to take lithium. To test out some of these assumptions, a questionnaire was sent out to all referrers to the ECT clinic. A total of 14 (53.8%) of 26 yielded a response. Nine (64%) of the 14 responders said that they would consider using lithium augmentation regimes after ECT. Most common reasons given in favor of lithium were “most effective with best evidence base” and “personal experience of it being effective.” Reasons given by those who did not use lithium augmentation included “adverse effect profile and toxicity,” “inconvenience of blood monitoring,” “new ways of working (resulting in lack of continuity in follow-up),” and “patient choice.” It is known that the monitoring of lithium needs improving. This was the subject of 1 of the Prescribing Observatory for Mental Health national audits in the United Kingdom.10 Readmission to hospital for further ECT is expensive; therefore it may be cost-effective to put additional resource into the improved take-up of lithium prescribing. Possible solutions include more regular feedback and updates to senior colleagues about post-ECT treatments, inbuilt reminders/prompts to clinicians once a patient has finished ECT, nurse-led lithium clinics for monitoring of lithium, or even ECT clinic staff becoming involved in medication decisions and postECT monitoring of medication. Effecting change is not easy and requires sustained effort. The ECT clinic in West Sussex is currently piloting various
36
www.ectjournal.com
methods to increase the prescribing of lithium and reduce relapse rate after successful ECT. REFERENCES 1. Sackeim HA, Hasket RF, Mulsant BH, et al. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy—a randomized controlled trial. JAMA. 2001;285:1299–1307. 2. Prudic J, Haskett RF, McCall WV, et al. Pharmacological strategies in the prevention of relapse after electroconvulsive therapy. J ECT. 2013;29:3–12. 3. Jelovac A, Kolshus E, McLoughlin DM. Relapse following successful electroconvulsive therapy for major depression. A meta-analysis. Neuropharmacology. 2013;38:2467–2474. 4. Von Schweder J. Post ECT pharmacotherapy: an update. Eur Psychiatry. 2009;24:74. 5. Van den Broek W, Birkenhager T, Mulder P, et al. Imipramine is effective in preventing relapse in electroconvulsive therapy-responsive depressed inpatients with prior pharmacotherapy treatment failure: a randomized, placebo-controlled trial. J Clin Psychiatry. 2006;76:263–268. 6. Kellner CH, Knapp RG, Petrides G, et al. Continuation electroconvulsive therapy versus pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry. 2006;63:1337–1344. 7. Waite J, Easton A, eds. The ECT Handbook. 3rd ed. Royal College of Psychiatrists, College Report CR176. London UK: RCPsych publications; 2012. 8. Guidance on the Use of Electroconvulsive Therapy. NICE Technology Appraisal Guidance 59; (Nov 2005). Available at: http://www.nice.org.uk/nicemedia/pdf/59ectfullguidance.pdf. 9. Depression: The Treatment and Management of Depression in Adults. NICE Clinical Guideline 90; (Oct 2009). Available at: http://www.nice.org.uk/nicemedia/live/12329/45888/45888.pdf. 10. Prescribing Observatory for Mental Health (2012). Topic 7c. Monitoring of Patients Prescribed Lithium: Supplementary Report. POMH CCQI 118 (data on file).
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
