Sandbox

Jump to navigation Jump to search

Major depressive disorder Microchapters

Home

Major Depressive Disorder (Patient Information)

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Major depressive disorder from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Substance/Medication-induced Depressive Disorder

Depressive Disorder due to a Medical Condition

Diagnosis

Diagnostic Criteria

History and Symptoms

Physical Examination

Laboratory Findings

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Psychotherapy

ECT

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Follow-up

Follow-Up

Case Studies

Case #1

Sandbox On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Sandbox

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2] Aiden Nguyen[3]

Overview

Electroconvulsive therapy (ECT) is the most effective acute treatment for severe major depressive disorder (MDD). Most guidelines position ECT as first-line for severe, life-threatening episodes (psychotic features, catatonia, high suicide risk, or food/fluid refusal) and as second-line for severe MDD unresponsive to pharmacotherapy or psychotherapy. NICE is more restrictive. ECT is recommended (VA/DoD 2022, Strong for, despite very low-quality evidence, because of the life-threatening nature of these presentations) among patients with severe MDD who have catatonia, psychotic depression, severe suicidality, a history of good response to ECT, or a need for a rapid, definitive response, and among patients with poor response or intolerance to multiple antidepressants. MDD with malignant catatonia requires urgent ECT. Modified ECT (general anesthesia plus neuromuscular blockade) is the standard technique. Right unilateral (RUL) ECT at about 6 times seizure threshold is commonly used first in nonpsychotic patients. Ultrabrief-pulse RUL causes fewer cognitive effects but is less effective and requires more sessions than brief-pulse RUL. Bitemporal placement is favored for psychotic, catatonic, or urgent presentations. IV ketamine might be reasonable as an alternative to ECT in nonpsychotic outpatients with treatment-resistant depression (TRD) after shared decision-making. Relapse after a successful ECT course is common, and expert consensus supports lithium plus an antidepressant, with tapered continuation/maintenance ECT in high-risk patients.

Electroconvulsive Therapy

Regulatory Status

  • In 2018 the US FDA reclassified ECT devices from class III (high risk) to class II (moderate risk, special controls).[1]
  • The class II indication is severe major unipolar or bipolar depressive episodes, or catatonia, in patients aged 13 years or older whose illness is treatment-resistant or who need a rapid response because of the severity of their psychiatric or medical condition.[2]
  • The FDA did not define "severe" or "treatment-resistant." Other uses are left to clinical judgment.

Indications

VA/DoD 2022 (Strong for, very low-quality evidence)

Offer ECT, with or without psychotherapy, to patients with severe MDD and any of the following:[3]

  • Catatonia
  • Psychotic depression
  • Severe suicidality
  • History of good response to ECT
  • Need for a rapid, definitive response on medical or psychiatric grounds
  • Risks of other treatments exceed the risks of ECT (for example, comorbidities that make ECT the safest option)
  • Poor response or intolerable side effects to multiple antidepressants

Other International Guidelines

Older guidelines (APA 2010, CANMAT 2016, RANZCP 2015, WFSBP 2013, NICE 2009), as summarized in the background of Cochrane review protocols.[4] These positions predate the CANMAT 2023 and NICE 2022 (NG222) updates.[5] NICE has historically restricted ECT to severe, life-threatening illness or failure of an adequate trial of other treatments, in contrast with APA, WFSBP, RCPsych, RANZCP, and CANMAT, which do not regard ECT as a last resort.[6]

  • First-line for depression with psychosis, catatonia, refusal to eat or drink, or high suicide risk.
  • First-line for treatment-resistant acute episodes (CANMAT, NICE, WFSBP).
  • Pregnancy: first-line when medication is contraindicated (WFSBP). APA and RANZCP suggest ECT as a treatment of choice for severe depression in pregnancy.

Catatonia

  • Start ECT as soon as possible after limited response to benzodiazepines, or for severe catatonia. Start urgently for any malignant catatonia.[7]
  • ECT improves 80–100% of catatonia, including up to 60% of benzodiazepine non-responders.[7] The BAP consensus guideline reports similar response ranges for ECT (59–100%) and benzodiazepines (66–100% in Western studies); both are first-line treatments.[8]
  • Bitemporal placement is generally preferred; no high-quality comparison exists. RUL can be considered in treatment-naïve patients or those with prior RUL response.[7]
  • Estimates of sessions needed differ: effects after 4–6 bilateral sessions in one review,[9] versus 12 or more sessions for meaningful response or remission in the APA document.[7]
  • Many patients benefit from concurrent benzodiazepine maintenance alongside ECT.[7]

Timing of Referral in Treatment-Resistant Depression

  • In a US decision-analytic model, offering ECT after failure of 2 lines of pharmacotherapy and/or psychotherapy cost about $54,000 per QALY gained and was the strategy most likely to be cost-effective.[10][2] This is modeling evidence, not a guideline threshold.
  • Patients with life-threatening features (suicidality, psychosis, dehydration, malnutrition, catatonia) may receive ECT as primary treatment without serial drug trials.[2]

Efficacy

  • Versus sham and pharmacotherapy: ECT was superior to sham ECT (6 trials, n=256; SES −0.91) and to pharmacotherapy (18 trials, n=1,144; SES −0.80, about 5.2 HDRS points) in the UK ECT Review Group meta-analysis. Bilateral ECT was moderately more effective than unilateral ECT (22 trials, n=1,408; SES −0.32), although many unilateral trials likely underdosed. Most trials were old and small.[11][12]
  • Treatment-resistant MDD: Pooled response rates are 60–80% and remission rates 50–60%.[2]
  • Speed of response: In the CORE study, 75% of 217 completers remitted, and 65% of remitters did so by week 4.[12] In older adults (PRIDE phase 1), the mean number of treatments to remission was 7.3.[13]
  • Predictors of higher efficacy: psychotic depression, catatonia, older age, inpatient and research settings.
  • Predictors of lower efficacy: prolonged episode, extensive medication resistance, comorbid personality disorder, community or outpatient settings.[12]
  • Suicide and mortality (observational data):
    • A propensity-matched Ontario cohort found no clinically significant increase in serious medical events and significantly lower suicide death with ECT.[14]
    • A VA propensity-matched cohort found no excess mortality after ECT and a lower risk of non-suicide death (RR 0.79, 95% CI 0.66–0.95).[15]

ECT Versus Ketamine

Study Population Key finding
KetECT (Ekstrand et al., 2022; n=186)[16] Swedish inpatients, unipolar depression, ECT candidates; unlike ELEKT-D, did not exclude psychotic depression[17] ECT superior: remission 63% vs 46%
ELEKT-D (Anand et al., 2023)[17] Nonpsychotic TRD, 89% outpatient IV ketamine noninferior to ECT for response. Greater memory decline with ECT at end of treatment, similar at 1 month. ECT remission was low: 21.8% on MADRS (vs 37.9% with ketamine) and 20.0% on QIDS-SR (vs 32.3%). ECT began with ultrabrief RUL, the acute phase was limited to 9 treatments, and the sample was mostly outpatients, which limits generalizability to classic ECT-responsive populations[18]
Menon et al., 2023 (5 RCTs, n=278)[19] Mixed ECT superior for response (RR 1.27) and remission (RR 1.43). All trials at high risk of bias
Petrucci et al., 2024 (6 RCTs, n=655)[20] Mixed Ketamine not noninferior overall; inferior in inpatients (risk difference −0.15). Less myalgia and better cognition with ketamine, more dissociation
  • ECT remains preferred for inpatients and for psychotic, catatonic, or very severe depression.
  • IV ketamine might be reasonable for nonpsychotic outpatient TRD after shared decision-making.[18]
  • IV racemic ketamine is off-label for depression. Intranasal esketamine is FDA-approved for TRD in adults (as monotherapy or with an oral antidepressant) and for depressive symptoms in adults with MDD with acute suicidal ideation or behavior (with an oral antidepressant). Its effectiveness in preventing suicide or reducing suicidal ideation or behavior has not been demonstrated, and it does not replace hospitalization when clinically warranted.[21] See Major depressive disorder medical therapy.
  • ECT is more effective than TMS, especially in psychotic depression.[22]

Technique

  • Anesthesia: Modified ECT, with a short-acting IV anesthetic plus a muscle relaxant, is best practice.[23] Evidence on whether the choice of anesthetic agent affects efficacy is uncertain.[4]
  • Pulse width: Brief pulse is 0.5–2.0 ms. Ultrabrief pulse is <0.5 ms (typically 0.25–0.3 ms).[4]
    • Ultrabrief RUL causes fewer cognitive effects in all domains tested. However, it is slightly less effective than brief-pulse RUL (SMD 0.25; remission OR 0.71; NNT about 12) and requires more sessions.[24]
    • In a double-blind RCT (n=116), remission among completers was 68.4% with brief pulse vs 49.0% with ultrabrief pulse, with no difference in the cognitive measures tested.[25]
    • A 2026 meta-analysis reported pooled remission of 32.2% with ultrabrief high-dose RUL.[26]
  • Electrode placement:
    • Right unilateral (RUL): good efficacy with fewer cognitive effects, but the dose must be clearly suprathreshold. Guidance recommends about 6 times seizure threshold for RUL and about 1.5 times threshold for bitemporal or bifrontal placement (CPA 2010; RANZCP 2019).[4]
    • Bitemporal (BT): often favored for severe, psychotic, or catatonic presentations and urgent need. Causes more cognitive effects.[27][7]
    • Bifrontal: an alternative placement.
  • Dosing: Seizure threshold varies up to about 50-fold between patients and is higher with bilateral placement, older age, and male sex. Empirical stimulus-dose titration at the first session individualizes dosing.[28] Efficacy tracks seizure quality (ictal amplitude, postictal suppression) more than duration. EEG monitoring confirms seizure termination.
  • Schedule:
    • Usually 2–3 sessions per week for 6–12 treatments total.[4]
    • Catatonia may need 12 or more sessions. Daily sessions can be used for malignant catatonia or inanition.[7]
    • Continue until remission or plateau. There is no fixed number of treatments.

Pre-ECT Evaluation

  • There are no absolute contraindications.[12]
  • Workup: medical and neurologic history and examination, anesthesia evaluation, and informed consent with capacity assessment. Add cardiology consultation when there are cardiac risk factors or known disease.[2]
  • Higher-risk conditions requiring optimization:
    • Recent MI, unstable ischemia, or arrhythmia
    • Recent stroke or intracranial hemorrhage
    • Raised intracranial pressure
    • Retinal detachment[3]
    • Intracranial aneurysm or vascular malformation, which requires tight ictal blood pressure control with short-acting β-blockers or calcium-channel blockers[29]
  • Usually safe with precautions: pacemakers and ICDs (ICD sensing is typically suspended during treatment), older age, and pregnancy.[12]

Concurrent Medication Management

Decisions are individualized. Most psychotropics appear to have little effect on seizure threshold during titration.[30]

Medication class Management
Lithium Combined use was associated with delirium in a US inpatient database: 5.7% vs 0.6% with ECT alone (OR 11.7, 95% CI 7.55–17.99).[31] If lithium is continued, keep levels in the low therapeutic range. One naturalistic bipolar cohort used 0.3–0.4 mEq/L and held the night-before dose (expert practice, not trial-derived).[28] In PRIDE phase 2, neurocognitive outcomes did not differ between continuation ECT plus venlafaxine–lithium and venlafaxine–lithium alone. Both arms took lithium, so this does not isolate a lithium effect.[32] A 2026 meta-analysis of 11 mostly retrospective studies found a nonsignificant association with confusional states (OR 2.09, 95% CI 0.94–4.66), which became significant with an alternative estimator (OR 2.38). Publication bias suggests the true risk may be underestimated.[33]
Anticonvulsants and benzodiazepines Raise seizure threshold and cause missed or short seizures. Options:[28]
* Hold doses the night before and morning of ECT
* Use a higher stimulus dose
* Use remifentanil to spare barbiturate
* Switch the anesthetic to ketamine or etomidate
* Give flumazenil before stimulation if on high-dose benzodiazepines
* Hyperventilate (avoid excess hyperventilation in pregnancy)[34]
Exception – catatonia: benzodiazepines are often continued during ECT, and concurrent maintenance can be beneficial; avoid abrupt withdrawal.[7]
Antidepressants Generally well tolerated. TCAs may augment response. Use caution with high-dose venlafaxine or other SNRIs. Starting the continuation antidepressant during the course is common practice, but in one RCT, starting nortriptyline or venlafaxine at the beginning of the ECT course did not reduce later relapse rates.[28]
Antipsychotics, including clozapine Can be used safely with ECT.

Adverse Effects

  • Mortality:
    • About 2.1 ECT-attributed deaths per 100,000 treatments in a pooled analysis of more than 766,000 treatments.[35]
    • In VA data (123,479 treatments), all-cause mortality within 7 days was 3.08 per 10,000 treatments. This figure counts all deaths in the window, not deaths attributed to ECT, which explains the difference from the pooled ECT-attributed estimate.[15]
    • Duma et al. reported all-cause mortality of 0.06 per 1,000 treatments (0.42 per 1,000 patients); 29% of deaths were cardiac.[36]
  • Cardiopulmonary events are the most frequent serious complications (<1% of treatments). Arrhythmia occurs in about 4.66 per 1,000 treatments and acute heart failure in about 2.44 per 1,000.[36] Other serious events include prolonged apnea, aspiration, and prolonged seizures.
    • Major adverse cardiac events occur in about 1 in 50 patients and after about 1 in 200–500 treatments.[36] In a Swedish propensity-matched cohort of inpatients with depression, ECT was associated with fewer major adverse cardiovascular events at 1 year (1.4% vs 2.3%; HR 0.65).[37] A Danish registry found a short-term (0–30 day) cardiac signal in patients without somatic comorbidity, based on few events.[38]
  • Common, self-limited effects: headache, jaw pain, myalgia, nausea, fatigue, and transient postictal confusion.
  • Cognitive effects:[2]
    • Anterograde amnesia usually resolves within 2–4 weeks.
    • Retrograde (autobiographical) amnesia builds over the course and resolves over weeks to months. It persists for more than 1 year in some patients.
    • Delirium is rare and may require pausing or stopping the course.
    • Risk is higher with bitemporal placement, more treatments, and higher charge. Risk is lower with RUL placement, ultrabrief pulse, and shorter courses.
    • Meta-analyses show return to or above baseline in most cognitive domains after more than 1 month.[39]
    • A Danish cohort of 168,015 patients with affective disorders found no increased dementia risk after ECT.[40] A 2026 review of administrative-data studies concluded that, after adjustment for confounding, most studies show no increase in dementia or major cardiovascular events, consistent with neuroimaging studies.[41]
    • The MMSE is insensitive. Assess autobiographical memory, verbal fluency, and verbal memory.[39]

Special Populations

  • Older adults:
    • ECT is safe and response rates are equal or higher.[22] In a Swedish register study of adults aged 75 and older, ECT was associated with lower 12-month all-cause mortality. This finding is observational and subject to selection bias.[42]
    • In PRIDE phase 1 (n=240, age ≥60), RUL ultrabrief ECT at 6 times seizure threshold plus venlafaxine gave 61.7% intention-to-treat remission and 70% response.[13]
    • In an Ontario cohort, falls and pneumonia were the most common severe medical events. Risk was highest in older adults, those with high ASA scores, and those with ischemic heart disease. Events were rare (<1%) in patients younger than 65.[43]
  • Pregnancy:
    • There are no RCTs. An overview of reviews supports relative safety. Reported adverse events include fetal bradycardia, vaginal bleeding, and abdominal pain, but the literature is biased toward reporting adverse outcomes.
    • Requires a multidisciplinary team and obstetric involvement.[3] The APA and ACOG have jointly endorsed ECT as safe and effective for refractory depression in pregnancy.[44]
    • Risks: aspiration and difficult intubation (airway edema, reduced lower esophageal sphincter tone) and reduced uteroplacental perfusion. Nonsustained fetal heart rate abnormalities are the most common adverse outcome. Limited data show no increase in placental abruption, preterm delivery, prolonged fetal heart rate abnormalities, or stillbirth.[44]
    • Precautions: obstetric consultation; aspiration prophylaxis (antacid, withhold anticholinergics); left lateral uterine displacement after 20 weeks' gestation; fetal heart rate monitoring (for example, Doppler) before and after each treatment, with more intensive monitoring in late or high-risk pregnancy; avoid excess hyperventilation; prefer glycopyrrolate over atropine, which crosses the placenta.[44][34] Fetal monitoring recommendations vary by gestational age and between centers.
    • In a Swedish national registry (97 pregnancies, 416 sessions, 2008–2021), response rates were high and no adverse events were directly attributable to ECT.[45]
  • Adolescents (13 years and older): Included in the FDA indication. AACAP and RANZCP support ECT for severe affective or psychotic illness or catatonia after pharmacologic failure.[4]

Continuation and Maintenance ECT (Relapse Prevention)

  • Relapse risk exceeds 50% within months if all treatment stops after remission.[23] Relapse reaches up to 50% within 1 year despite treatment.[46]
  • In a 24-week RCT after successful ECT, relapse was 84% on placebo, 60% on nortriptyline, and 39% on nortriptyline plus lithium.[2] Even with continuation pharmacotherapy, about 51% relapse by 12 months, mostly (38%) within the first 6 months, so continuation treatment should start immediately.[47]
  • VA/DoD: follow ECT with antidepressant maintenance, or with repeated ECT if antidepressants are not tolerated.[3]
  • Trials:
    • CORE: continuation ECT was equivalent to lithium plus nortriptyline. Only about 46% of each arm remained relapse-free at 6 months.[48]
    • PRIDE (n=120 older adult remitters): four continuation ECT sessions plus as-needed ECT (STABLE algorithm), added to venlafaxine plus lithium, gave lower HAM-D scores at 24 weeks than medication alone (adjusted difference 4.2 points, 95% CI 1.6–6.9). Relapse was 13.1% vs 20.3%, and MMSE did not differ.[49]
  • Meta-analytic data:
    • Continuation/maintenance ECT (C/M-ECT) plus pharmacotherapy reduced relapse versus pharmacotherapy alone: RR 0.64 (95% CI 0.41–0.98) at 6 months and RR 0.46 (95% CI 0.21–0.98) at 1 year (5 RCTs, n=436).[50]
    • A 2025 RCT-only meta-analysis (4 trials, n=254) found that continuation ECT plus pharmacotherapy reduced 6-month relapse versus pharmacotherapy alone (RR 0.57, 95% CI 0.37–0.88; NNT 7), with similar dropout.[51]
    • A systematic review of 20 studies found fewer relapses and no consistent cognitive harm, with low or very-low certainty evidence.[52]
  • Registry data: In a Danish self-controlled study, C/M-ECT was associated with a hospitalization IRR of 0.51 after the acute course.[53]
  • 2026 global Delphi consensus (expert opinion):[46]
    • Give all patients lithium plus an antidepressant (TCA, venlafaxine, or a previously effective agent).
    • Taper C/M-ECT rather than stopping abruptly in patients at high relapse risk and in those with severe or psychotic depression.
    • Use psychotherapy as an adjunct only.
    • No consensus on rTMS, esketamine, or treatment duration beyond 6 months.

Clinical Recommendations

  1. Offer ECT early, not as a last resort, in severe MDD with psychosis, catatonia, severe suicidality, prior ECT response, need for rapid response, or failure of or intolerance to multiple antidepressants (VA/DoD, Strong for, very low-quality evidence).[3] Refusal of food or fluids is an additional first-line indication in APA, RANZCP, and WFSBP guidance.[4]
  2. Consider ECT after failure of 2 adequate lines of pharmacotherapy and/or psychotherapy in severe TRD (health-economic modeling, not a guideline threshold).[10]
  3. Start ECT urgently for catatonia unresponsive to lorazepam and for malignant catatonia.
  4. For most nonpsychotic patients, start with titrated RUL ECT at about 6 times seizure threshold. Choose brief or ultrabrief pulse based on the relative priority of efficacy versus cognitive tolerability, and recognize that ultrabrief pulse is less effective and needs more sessions. Use bitemporal placement, or switch to it, for psychotic, catatonic, or life-threatening illness, or when RUL fails.
  5. Complete a pre-ECT medical and anesthesia evaluation. Add cardiology input when there is cardiac risk, and involve neurology and neurosurgery for aneurysm or raised intracranial pressure.
  6. Reconcile medications: lower or hold lithium, minimize or time benzodiazepines and anticonvulsants (except in catatonia, where benzodiazepines are often continued), and continue antipsychotics. Starting the continuation antidepressant during the course is common practice, but it did not reduce later relapse in one RCT.[28][7]
  7. Monitor depression ratings every week or every few sessions, plus targeted cognitive assessment (autobiographical memory, verbal fluency) at baseline, during, and after the course.
  8. Plan relapse prevention before the course ends: lithium plus an antidepressant for all patients, and tapered C/M-ECT for high-risk patients.

References

  1. ↑ US Food and Drug Administration. Neurological Devices; Reclassification of Electroconvulsive Therapy Devices; Effective Date of Requirement for Premarket Approval for Electroconvulsive Therapy for Certain Specified Intended Uses. Final order. Fed Regist. 2018;83:66103-66124.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Espinoza RT, Kellner CH (2022). "Electroconvulsive Therapy". N Engl J Med. 386 (7): 667–672. doi:10.1056/NEJMra2034954.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 US Department of Veterans Affairs and Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder, Version 4.0. 2022. Guideline page
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Munkholm K, Jørgensen KJ, Paludan-Müller AS. Electroconvulsive therapy for depression (protocol). Cochrane Database Syst Rev. 2021.
  5. ↑ Lam RW, Kennedy SH, Adams C; et al. (2024). "Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults". Can J Psychiatry. 69 (9): 641–687. doi:10.1177/07067437241245384. PMID 38711351 Check |pmid= value (help).
  6. ↑ Kellner CH, Obbels J, Sienaert P. When to consider electroconvulsive therapy (ECT). Acta Psychiatr Scand. 2020.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 American Psychiatric Association. Resource Document on Catatonia. 2025. APA
  8. ↑ Rogers JP, Oldham MA, Fricchione G, et al. Evidence-based consensus guidelines for the management of catatonia: recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2023.
  9. ↑ Heckers S, Walther S. Catatonia. N Engl J Med. 2023.
  10. ↑ 10.0 10.1 Ross EL, Zivin K, Maixner DF. Cost-effectiveness of electroconvulsive therapy vs pharmacotherapy/psychotherapy for treatment-resistant depression in the United States. JAMA Psychiatry. 2018.
  11. ↑ UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet. 2003;361(9360):799-808.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 Lisanby SH (2007). "Electroconvulsive Therapy for Depression". N Engl J Med. 357 (19): 1939–1945. doi:10.1056/NEJMra063950.
  13. ↑ 13.0 13.1 Kellner CH, Husain MM, Knapp RG; et al. (2016). "Right Unilateral Ultrabrief Pulse ECT in Geriatric Depression: Phase 1 of the PRIDE Study". Am J Psychiatry. 173 (11): 1101–1109. PMID 27418379.
  14. ↑ Kaster TS, Vigod SN, Gomes T; et al. (2021). "Risk of serious medical events in patients with depression treated with electroconvulsive therapy: a propensity score-matched, retrospective cohort study". Lancet Psychiatry. 8 (8): 686–695. doi:10.1016/S2215-0366(21)00168-1.
  15. ↑ 15.0 15.1 Watts BV, Peltzman T, Shiner B. Mortality After Electroconvulsive Therapy. Br J Psychiatry. 2021. PMID 35048831.
  16. ↑ Ekstrand J, Fattah C, Persson M, et al. Racemic Ketamine as an Alternative to Electroconvulsive Therapy for Unipolar Depression: A Randomized, Open-Label, Non-Inferiority Trial (KetECT). Int J Neuropsychopharmacol. 2022;25(5):339-349.
  17. ↑ 17.0 17.1 Anand A, Mathew SJ, Sanacora G; et al. (2023). "Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression". N Engl J Med. 388 (25): 2315–2325. doi:10.1056/NEJMoa2302399.
  18. ↑ 18.0 18.1 Mathew SJ, Jha MK, Anand A. Choosing Between Ketamine and Electroconvulsive Therapy for Outpatients With Treatment-Resistant Depression—Advantage Ketamine? JAMA Psychiatry. 2023.
  19. ↑ Menon V, Varadharajan N, Faheem A, Andrade C. Ketamine vs Electroconvulsive Therapy for Major Depressive Episode: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2023;80(6):639-642.
  20. ↑ Petrucci ABC, Fernandes JVA, Reis IA, et al. Ketamine Versus Electroconvulsive Therapy for Major Depressive Episode: An Updated Systematic Review and Non-Inferiority Meta-Analysis. Psychiatry Res. 2024.
  21. ↑ Spravato (esketamine hydrochloride) nasal spray. Prescribing information. Janssen; US Food and Drug Administration. DailyMed
  22. ↑ 22.0 22.1 Marx W, Penninx BWJH, Solmi M; et al. (2023). "Major depressive disorder". Nat Rev Dis Primers. 9: 44. doi:10.1038/s41572-023-00454-1.
  23. ↑ 23.0 23.1 Conroy SK, Holtzheimer PE. Neuromodulation Strategies for the Treatment of Depression. Am J Psychiatry. 2021;178(12):1082-1088.
  24. ↑ Tor PC, Bautovich A, Wang MJ; et al. (2015). "A Systematic Review and Meta-Analysis of Brief Versus Ultrabrief Right Unilateral Electroconvulsive Therapy for Depression". J Clin Psychiatry. 76 (9): e1092–e1098. PMID 26213985.
  25. ↑ Spaans HP, Verwijk E, Comijs HC, et al. Efficacy and cognitive side effects after brief pulse and ultrabrief pulse right unilateral electroconvulsive therapy for major depression: a randomized, double-blind, controlled study. J Clin Psychiatry. 2013;74(11):e1029-e1036.
  26. ↑ Jelovac A, McLoughlin DM. Ultrabrief pulse electroconvulsive therapy for depression: a systematic review and meta-analysis. Mol Psychiatry. 2026.
  27. ↑ Leaver AM, et al. Electroconvulsive therapy: mechanisms and electrode placement. Biol Psychiatry. 2022.
  28. ↑ 28.0 28.1 28.2 28.3 28.4 Janjua AU, Dhingra AL, Greenberg R, McDonald WM. The Efficacy and Safety of Concomitant Psychotropic Medication and Electroconvulsive Therapy (ECT). CNS Drugs. 2020.
  29. ↑ Mehdi SMA, Devanand DP. Electroconvulsive therapy in patients with intracranial aneurysms or vascular malformations. J Geriatr Psychiatry Neurol. 2021.
  30. ↑ Chiao S, et al. Psychotropic medications and seizure threshold during ECT. J ECT. 2020.
  31. ↑ Patel RS, Bachu A, Youssef NA (2020). "Combination of Lithium and Electroconvulsive Therapy (ECT) Is Associated With Higher Odds of Delirium and Cognitive Problems in a Large National Sample Across the United States". Brain Stimul. 13 (1): 15–19. PMID 31492631.
  32. ↑ Lisanby SH, McClintock SM, McCall WV, et al. Longitudinal Neurocognitive Effects of Combined ECT and Pharmacotherapy in Major Depressive Disorder in Older Adults: Phase 2 of the PRIDE Study. Am J Geriatr Psychiatry. 2022;30(1):15-28.
  33. ↑ Van den Eynde L, Takamiya A, Vansteelandt K, et al. Lithium, Electroconvulsive Therapy and Cognition: A Systematic Review and Meta-Analysis. Acta Psychiatr Scand. 2026.
  34. ↑ 34.0 34.1 Ward HB, Fromson JA, Cooper JJ, De Oliveira G, Almeida M. Recommendations for the use of ECT in pregnancy: literature review and proposed clinical protocol. Arch Womens Ment Health. 2018.
  35. ↑ Tørring N, Sanghani SN, Petrides G, Kellner CH, Østergaard SD (2017). "The mortality rate of electroconvulsive therapy: a systematic review and pooled analysis". Acta Psychiatr Scand. 135 (5): 388–397. doi:10.1111/acps.12721.
  36. ↑ 36.0 36.1 36.2 Duma A, Maleczek M, Panjikaran B, et al. Major Adverse Cardiac Events and Mortality Associated with Electroconvulsive Therapy: A Systematic Review and Meta-analysis. Anesthesiology. 2019;130(1):83-91.
  37. ↑ Nordenskjöld A, Güney P, Nordenskjöld AM. Major adverse cardiovascular events following electroconvulsive therapy in depression: a register-based nationwide Swedish cohort study with 1-year follow-up. J Affect Disord. 2022;296:298-304.
  38. ↑ Osler M, Rozing MP, Jorgensen MB, Jorgensen A. Mortality and acute somatic events following electroconvulsive therapy in patients with pre-existing somatic comorbidity. World J Biol Psychiatry. 2022;23(5):390-401.
  39. ↑ 39.0 39.1 Landry M, Moreno A, Patry S, Potvin S, Lemasson M. Current Practices of Electroconvulsive Therapy in Mental Disorders: A Systematic Review and Meta-Analysis of Short and Long-Term Cognitive Effects. J ECT. 2021.
  40. ↑ Osler M, Rozing MP, Christensen GT, Andersen PK, Jørgensen MB. Electroconvulsive therapy and risk of dementia in patients with affective disorders: a cohort study. Lancet Psychiatry. 2018;5(4):348-356.
  41. ↑ Kaster TS, Rhee TG, Adler E, Kirov G. Electroconvulsive therapy: improved understanding of long-term risks and benefits from advances in administrative health data. Br J Psychiatry. 2026.
  42. ↑ Hedna K, et al. ECT and mortality in adults aged 75 years and older: Swedish register study. Int J Geriatr Psychiatry. 2024.
  43. ↑ Blumberger DM, Seitz DP, Herrmann N, et al. Low medical morbidity and mortality after acute courses of electroconvulsive therapy in a population-based sample. Acta Psychiatr Scand. 2017;136(6):583-593.
  44. ↑ 44.0 44.1 44.2 Jones SI, Boettcher LB, Kuller JA. Perinatal depression (letter). JAMA. 2026.
  45. ↑ Arnison T, Rask O, Nordenskjöld A, Movahed Rad P. Safety of and response to electroconvulsive therapy during pregnancy: results from population-based nationwide registries. Acta Psychiatr Scand. 2024.
  46. ↑ 46.0 46.1 Rovers JJE, van Eijndhoven PFP, Abbott C, et al. A Global Delphi-Based Expert Consensus on Relapse Prevention Strategies Following Successful Electroconvulsive Therapy for Major Depressive Disorder. Am J Psychiatry. 2026.
  47. ↑ Jelovac A, Kolshus E, McLoughlin DM. Relapse following successful electroconvulsive therapy for major depression: a meta-analysis. Neuropsychopharmacology. 2013;38(12):2467-2474.
  48. ↑ Kellner CH, Knapp RG, Petrides G; et al. (2006). "Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE)". Arch Gen Psychiatry. 63 (12): 1337–1344. doi:10.1001/archpsyc.63.12.1337.
  49. ↑ Kellner CH, Husain MM, Knapp RG, et al. A Novel Strategy for Continuation ECT in Geriatric Depression: Phase 2 of the PRIDE Study. Am J Psychiatry. 2016;173(11):1110-1118. PMID 27418381.
  50. ↑ Elias A, Phutane VH, Clarke S, Prudic J. Electroconvulsive therapy in the continuation and maintenance treatment of depression: systematic review and meta-analyses. Aust N Z J Psychiatry. 2018;52(5):415-424.
  51. ↑ Jelovac A, Braithwaite R, Kellner CH, McLoughlin DM. Continuation electroconvulsive therapy combined with pharmacotherapy for depression relapse prevention: a systematic review and meta-analysis. Psychol Med. 2025.
  52. ↑ Rowland T, et al. Continuation and maintenance ECT: a systematic review. J ECT. 2023.
  53. ↑ Jørgensen A, Gronemann FH, Rozing MP, Jørgensen MB, Osler M. Clinical outcomes of continuation and maintenance electroconvulsive therapy. JAMA Psychiatry. 2024.
Retrieved from "https://www.wikidoc.org/index.php?title=Sandbox&oldid=1746859"