Elsevier

Journal of Affective Disorders

Volume 227, February 2018, Pages 627-632
Journal of Affective Disorders

Research paper
Electroconvulsive therapy and age: Age-related clinical features and effectiveness in treatment resistant major depressive episode

https://doi.org/10.1016/j.jad.2017.11.064Get rights and content

Highlights

  • Clinical features, treatment outcome and tolerability were compared among young (18–45 years), middle age (46–64 years) and old (> 65 years) drug resistant major depressive patients treated with ECT.

  • Our data suggest that the short-term ECT outcome in the treatment of depression in elderly is equivalent to that of young patients.

  • Old patients reported faster ECT response than younger ones and required less sessions to achieve response and remission.

  • The cognitive impairment associated with late-life depression may resolve after ECT as a consequence of symptomatic improvement.

Abstract

Objective

This study was aimed to compare clinical features, treatments outcomes and tolerability between young (18–45 years), middle age (46–64 years) and old (≥ 65 years) patients treated with bilateral ECT for treatment resistant major depressive episode.

Method

402 patients were evaluated 1 day prior to ECT and a week after the treatment termination using the Clinical Global Impression Scale (CGI), the Hamilton Rating Scale for Depression-17 items (HAM-D-17), the Brief Psychiatric Rating Scale (BPRS), the Young Mania Rating Scale (YMRS) and the Mini Mental State Examination (MMSE). Response was defined as a reduction of at least 50% from baseline on the HAM-D-17 score. Remission was defined as a score ≤ 7 on the HAM-D-17 at the final evaluation.

Results

Rates of response were not statistically different in the three groups (69.6% in old versus 63.5% in young and 55.5% in middle age groups). No significant differences were also observed in the proportions of remitters between the age groups (31.4% in young group, 27.7% in middle age group and 29.3% in old group). One week after the end of the ECT course the middle and old age groups showed a statistically significant increase in the MMSE score compared to baseline. We did not find significant differences between the three age groups in rates of premature drops-out due to ECT-related side effects.

Conclusion

Our data support the use of ECT in elderly patients with treatment-resistant major depressive episode, with rates of response around 70% and effectiveness being independent from age. In the old age group the baseline cognitive impairment improved after ECT and no life-threatening adverse event was detected.

Introduction

Electroconvulsive therapy (ECT) plays an important role in the treatment of geriatric depression for different reasons, such as low tolerance to medication, somatic comorbidity, drug-drug interactions, higher rates of treatment resistance and high risk of suicide (Conwell and Brent, 1995, Cooper et al., 2011, Dew et al., 2007, Flint, 2001, Katona, 2001, Young et al., 2004). Moreover, elderly patients are more vulnerable to the physical and functional complications of severe depression, so that they frequently require a fast and highly effective intervention (McCall et al., 1999). The proportion of patients receiving ECT increases with increasing age and people over 65 years constitute a large portion of patients undergoing this treatment (Case et al., 2013, Olfson et al., 1998, Thompson et al., 1994).

A large body of literature indicates that ECT is an effective treatment for elderly depressed patients: response rate ranges from 55% to 92% (Birkenhager et al., 2010, Bjolseth et al., 2015, Kellner et al., 2016, van der Wurff et al., 2003) and, compared to antidepressants, ECT proved to have higher percentages of remission and a faster speed of action (Flint and Rifat, 1998, Spaans et al., 2015).

The influence of age on the efficacy and tolerability of ECT has been the subject of interest of several authors. Uncontrolled retrospective studies in the 1980s and 1990s have reported in elderly patients a poorer outcome after ECT and an increased rate of sides effects (Burke et al., 1987, Cattan et al., 1990, Karlinsky and Shulman, 1984). Subsequent studies showed a better profile of ECT efficacy and safety in geriatric populations, but with conflicting results about the impact of advancing age on its effectiveness and tolerability. Thus, whereas some studies found an increase in response rates with the advancing of age (O'Connor et al., 2001, Tew et al., 1999, Wilkinson et al., 1993), other studies failed to detect a significant relation between age and ECT efficacy (Birkenhager et al., 2010, Brodaty et al., 2000, Damm et al., 2010). Furthermore, recent studies exploring the possible influence of different clinical and symptomatologic features on response to ECT in affective disorders, found no correlation between age and ECT outcome (Dombrovski et al., 2005, Haq et al., 2015, Kho et al., 2005, Medda et al., 2014, Perugi et al., 2012).

In the present study we aimed to investigate, in a large sample of patients with treatment-resistant depression, the influence of age on clinical features of ECT recipients, short-term ECT outcomes and ECT tolerability. Since ECT is frequently done in old patients, comparing its efficacy and tolerability with those of younger subjects is considered relevant.

Section snippets

Method

The study was conducted in a cohort of 402 patients with treatment-resistant major depressive episode who received ECT between January 2006 and April 2016 in the Department of Psychiatry of the University of Pisa, a tertiary care general psychiatric hospital in Italy. Study subjects were at least 18 years old and met the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) for a major depressive episode associated with major depressive disorder (MDD) (N

Results

Demographic and clinical features of the total sample and for the three age groups are reported in Table 1. The average age of the total sample was 52.1 ± 13.9 years, with 65.4% of the sample being women; proportions of women were 54% in young patients, 67.1% in middle age group, and 79.3% in old group (p = .000).

The age of onset of any psychiatric illness ranged from 21.2 ± 6 years in young patients to 39.5 ± 17.8 years in old ones, with a statistically significant difference between all the

Discussion

In our large sample of treatment-resistant depressed patients, old patients had the lowest percentage of males, highest age at onset of any psychiatric illness, shortest lengths of current depressive episodes, highest baseline HAM-D-17 scores and lowest baseline MMSE scores.

We observed that the percentage of women undergoing ECT increased with the increasing of age, from 55% in the young group to about 80% in the old group. Other epidemiological data reported an increased prevalence of women in

Acknowledgements

The authors would like to thank Sirio Moggi, Aldo Cosci and Luigi De Simone of Azienda Ospedaliero-Universitaria Pisana for anesthesia procedure.

Role of the funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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