Abstract
Purposeof Review
Following symptom remission with acute electroconvulsive therapy (ECT), maintenance ECT (M-ECT) is often used to prevent relapse. This review provides a concise summary of the evidence for M-ECT in various psychiatric disorders, outlines the cognitive adverse effects of M-ECT, and discusses clinical considerations while using M-ECT.
Recent Findings
Adjunctive M-ECT has considerable evidence for relapse prevention efficacy in depressive and psychotic disorders, preliminary evidence for efficacy in bipolar disorders, and insufficient evidence in other disorders such as obsessive–compulsive disorder. Careful selection of candidates for M-ECT may yield better results. Older adults represent a subgroup where M-ECT may be a safe and effective option for maintaining clinical remission. No significant cognitive adverse effects have been observed with M-ECT in controlled trials. Because no guidelines exist to inform decision-making on the duration and frequency of M-ECT sessions, clinicians may be better off using a symptom-driven, risk–benefit approach with periodic reassessment of the need for M-ECT every 3–6 months and following a tapering schedule for stopping M-ECT. Major gaps in available evidence include a lack of controlled observations and heterogeneity in sampling and ECT administration parameters that limit the generalizability of findings.
Summary
Adjuvant M-ECT is a safe and effective treatment option for maintaining clinical remission and improving patient-reported outcomes in depressive and psychotic disorders. For other disorders, insufficient evidence exists. There is a need for more rigorous, controlled efficacy and cost-effectiveness trials comparing M-ECT against maintenance pharmacotherapy, across contexts and indications, to inform clinical recommendations.
Similar content being viewed by others
Data availability
Not applicable.
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Heijnen WT, Birkenhäger TK, Wierdsma AI, Van Den Broek WW. Antidepressant pharmacotherapy failure and response to subsequent electroconvulsive therapy: a meta-analysis. J Clin Psychopharmacol. 2010;30:616–9.
Mart��nez-Amorós E, Serra P, Goldberg X, Urraca L, Palao DJ, Urretavizcaya M, Cardoner N. Clinical outcome after discontinuation of maintenance electroconvulsive therapy. A retrospective follow-up study. Rev Psiquiatr Salud Ment Engl Ed. 2020;13:5–10.
Gupta S, Hood C, Chaplin R. Use of continuation and maintenance electroconvulsive therapy: UK national trends. J ECT. 2011;27:77–80.
Weiner RD (2001) The practice of electroconvulsive therapy: recommendations for treatment, training, and privileging : a task force report of the American Psychiatric Association. American Psychiatric Association
Andrade C, Kurinji S. Continuation and maintenance ECT: a review of recent research. J ECT. 2002;18:149–58.
Methfessel I, Besse M, Belz M, Zilles-Wegner D. Effectiveness of maintenance electroconvulsive therapy—evidence from modifications due to the COVID-19 pandemic. Acta Psychiatr Scand. 2021;144:238–45.
Jelovac A, Kolshus E, McLoughlin DM. Relapse following successful electroconvulsive therapy for major depression: a meta-analysis. Neuropsychopharmacology. 2013;38:2467–74.
Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, Fitzsimons L, Moody BJ, Clark J. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry. 2000;57:425–34.
Shibasaki C, Takebayashi M, Fujita Y, Yamawaki S. Factors associated with the risk of relapse in schizophrenic patients after a response to electroconvulsive therapy: a retrospective study. Neuropsychiatr Dis Treat. 2015;11:67–73.
• Ward HB, Szabo ST, Rakesh G. Maintenance ECT in schizophrenia: a systematic review. Psychiatry Res. 2018;264:131–42. This was a large systematic review that showed the effectiveness of M-ECT for relapse prevention in schizophrenia with minimal cognitive adverse effects.
Kocamer Şahin Ş, Demir B, Elboğa G, Altındağ A, Elmalı E. The effects of maintenance electroconvulsive therapy on hospitalization rates. J Nerv Ment Dis. 2021;209:155–8.
Schwarz T, Loewenstein J, Isenberg KE. Maintenance ECT: indications and outcome. Convuls Ther. 1995;11:14–23.
Stegmann B, Gale C, Glue P. Maintenance ECT treatment in New Zealand: local and national data. Australas Psychiatry. 2023;31:90–4.
Ghaziuddin N, Yaqub T, Shamseddeen W, Reddy P, Reynard H, Maixner D. Maintenance electroconvulsive therapy is an essential medical treatment for patients with catatonia: a COVID-19 related experience. Front Psychiatry. 2021;12:670476.
Lambrichts S, Vansteelandt K, Crauwels B, et al. Relapse after abrupt discontinuation of maintenance electroconvulsive therapy during the COVID-19 pandemic. Acta Psychiatr Scand. 2021;144:230–7.
Martínez-Amorós E, Serra P, Bassa A, Palao DJ, Cardoner N. Discontinuation of maintenance electroconvulsive therapy: lessons learned from the COVID-19 pandemic. Rev Psiquiatr Salud Ment Engl Ed. 2022;15:154–5.
Van de Velde N, Geerts P-J, Tandt H, Vanderhasselt M-A, Titeca K, Lemmens G. Discontinuation of continuation or maintenance electroconvulsive therapy caused by the COVID-19 pandemic: a naturalistic study investigating relapse in patients with major depressive disorder. J ECT. 2021;37:230–7.
Kerman EF. Electroshock therapy: with special reference to relapses and an effort to prevent them. J Nerv Ment Dis. 1945;102:231–42.
Taylor PJ. Electroconvulsive therapy. Report of the task force of the American Psychiatric Association. Washington D.C. 1978. Pp 200. Br J Psychiatry. 1980;136:103–103.
• Brown ED, Lee H, Scott D, Cummings GG. Efficacy of continuation/maintenance electroconvulsive therapy for the prevention of recurrence of a major depressive episode in adults with unipolar depression: a systematic review. J ECT. 2014;30:195–202. This was a systematic review supporting the combined use of C-ECT or M-ECT and pharmacotherapy over pharmacotherapy alone in the prevention of relapse and recurrence in adults with unipolar depression.
Kellner CH, Knapp RG, Petrides G, et al. 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. 2006. https://doi.org/10.1001/archpsyc.63.12.1337.
Navarro V, Gastó C, Torres X, et al. Continuation/maintenance treatment with nortriptyline versus combined nortriptyline and ECT in late-life psychotic depression: a two-year randomized study. Am J Geriatr Psychiatry. 2008;16:498–505.
Serra M, Gastó C, Navarro V, Torres X, Blanch J, Masana G. Maintenance electroconvulsive therapy in elderly psychotic unipolar depression. Med Clin (Barc). 2006;126:491–2.
Gupta S, Tobiansky R, Bassett P, Warner J. Efficacy of maintenance electroconvulsive therapy in recurrent depression: a naturalistic study. J ECT. 2008;24:191–4.
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;173:1110–8.
Nordenskjöld A, von Knorring L, Ljung T, Carlborg A, Brus O, Engström I. Continuation electroconvulsive therapy with pharmacotherapy versus pharmacotherapy alone for prevention of relapse of depression: a randomized controlled trial. J ECT. 2013;29:86–92.
• 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;52:415–24.This was a meta-analysis showing the superiority of adjunctive C-ECT and M-ECT over pharmacotherapy in reducing the risk of relapse and recurrence of depression at 1 year following ECT-induced remission.
•• Rowland T, Mann R, Azeem S. The efficacy and tolerability of continuation and maintenance electroconvulsive therapy for depression: a systematic review of randomized and observational studies. J ECT. 2023;39:141. This was one of the latest systematic reviews showing reduced relapse rates in patients of depression receiving C/M-ECT with no effect on global cognitive function.
Russell JC, Rasmussen KG, O’Connor MK, Copeman CA, Ryan DA, Rummans TA. Long-term maintenance ECT: a retrospective review of efficacy and cognitive outcome. J ECT. 2003;19:4–9.
Nordenskjöld A, von Knorring L, Engström I. Rehospitalization rate after continued electroconvulsive therapy–a retrospective chart review of patients with severe depression. Nord J Psychiatry. 2011;65:26–31.
Hausmann A, Post T, Post F, Dehning J, Kemmler G, Grunze H. Efficacy of continuation/maintenance electroconvulsive therapy in the treatment of patients with mood disorders: a retrospective analysis. J ECT. 2019;35:122–6.
Post T, Kemmler G, Krassnig T, Brugger A, Hausmann A. Efficacy of continuation and maintenance electroconvulsive therapy (c/m ECT) in the treatment of patients with therapy-resistant affective disorders: a retrospective analysis. Neuropsychiatr. 2015;29:133–8.
Vanelle J-M, Loo H, Galinowski A, de Carvalho W, Bourdel M-C, Brochier P, Bouvet O, Brochier T, Olie J-P. Maintenance ECT in intractable manic-depressive disorders. J ECT. 1994;10:195.
Atashnama A, Aly H, Krishnan V, Howari R, Mayur P. Naturalistic outcomes of continuation right unilateral ultrabrief ECT in major depression: a retrospective chart review. Australas Psychiatry Bull R Aust N Z Coll Psychiatr. 2020;28:286–90.
Luccarelli J, McCoy TH, Seiner SJ, Henry ME. Maintenance ECT is associated with sustained improvement in depression symptoms without adverse cognitive effects in a retrospective cohort of 100 patients each receiving 50 or more ECT treatments. J Affect Disord. 2020;271:109–14.
Petrides G, Tobias KG, Kellner CH, Rudorfer MV. Continuation and maintenance electroconvulsive therapy for mood disorders: review of the literature. Neuropsychobiology. 2011;64:129–40.
Rabheru K, Persad E. A review of continuation and maintenance electroconvulsive therapy. Can J Psychiatry. 1997;42:476–84.
Van Schaik AM, Comijs HC, Sonnenberg CM, Beekman AT, Sienaert P, Stek ML. Efficacy and safety of continuation and maintenance electroconvulsive therapy in depressed elderly patients: a systematic review. Am J Geriatr Psychiatry. 2012;20:5–17.
Rapinesi C, Kotzalidis GD, Serata D, et al. Prevention of relapse with maintenance electroconvulsive therapy in elderly patients with major depressive episode. J ECT. 2013;29:61–4.
Gagné GG, Furman MJ, Carpenter LL, Price LH. Efficacy of continuation ECT and antidepressant drugs compared to long-term antidepressants alone in depressed patients. Am J Psychiatry. 2000;157:1960–5.
O’Connor DW, Gardner B, Presnell I, Singh D, Tsanglis M, White E. The effectiveness of continuation-maintenance ECT in reducing depressed older patients’ hospital re-admissions. J Affect Disord. 2010;120:62–6.
Odeberg H, Rodriguez-Silva B, Salander P, Mårtensson B. Individualized continuation electroconvulsive therapy and medication as a bridge to relapse prevention after an index course of electroconvulsive therapy in severe mood disorders: a naturalistic 3-year cohort study. J ECT. 2008;24:183–90.
Swoboda E, Conca A, König P, Waanders R, Hansen M. Maintenance electroconvulsive therapy in affective and schizoaffective disorder. Neuropsychobiology. 2001;43:23–8.
Chanpattana W. Combined ECT and clozapine in treatment-resistant mania. J ECT. 2000;16:204–7.
Kramer BA. ECT in elderly patients with schizophrenia. Am J Geriatr Psychiatry. 1999;7:171–4.
Gupta S, Austin R, Devanand DP. Lithium and maintenance electroconvulsive therapy. J ECT. 1998;14:241–4.
Nascimento AL, Appolinario JC, Segenreich D, Cavalcanti MT, Brasil MAA. Maintenance electroconvulsive therapy for recurrent refractory mania. Bipolar Disord. 2006;8:301–3.
Tsao CI, Jain S, Gibson RH, Guedet PJ, Lehrmann JA. Maintenance ECT for recurrent medication-refractory mania. J ECT. 2004;20:118–9.
Minnai GP, Salis PG, Oppo R, Loche AP, Scano F, Tondo L. Effectiveness of maintenance electroconvulsive therapy in rapid-cycling bipolar disorder. J ECT. 2011;27:123–6.
Petrides G, Dhossche D, Fink M, Francis A. Continuation ECT: relapse prevention in affective disorders. Convuls Ther. 1994;10:189–94.
Lisanby SH, Sampson S, Husain MM, Petrides G, Knapp RG, McCall WV, Young RC, Prudic J, Kellner CH. Toward individualized post-electroconvulsive therapy care: piloting the Symptom-Titrated, Algorithm-Based Longitudinal ECT (STABLE) intervention. J ECT. 2008;24:179–82.
Weiner RD, Reti IM. Key updates in the clinical application of electroconvulsive therapy. Int Rev Psychiatry Abingdon Engl. 2017;29:54–62.
Chanpattana W, Chakrabhand ML, Sackeim HA, Kitaroonchai W, Kongsakon R, Techakasem P, Buppanharun W, Tuntirungsee Y, Kirdcharoen N. Continuation ECT in treatment-resistant schizophrenia: a controlled study. J ECT. 1999;15:178–92.
Youn T, Jeong SH, Kim YS, Chung IW. Long-term clinical efficacy of maintenance electroconvulsive therapy in patients with treatment-resistant schizophrenia on clozapine. Psychiatry Res. 2019;273:759–66.
Yang Y, Cheng X, Xu Q, Li R, Liu Z, Wang L, Zhang Y, Ren G, Liu J. The maintenance of modified electroconvulsive therapy combined with risperidone is better than risperidone alone in preventing relapse of schizophrenia and improving cognitive function. Arq Neuropsiquiatr. 2016;74:823–8.
Petrides G, Malur C, Braga RJ, et al. Electroconvulsive therapy augmentation in clozapine-resistant schizophrenia: a prospective, randomized study. Am J Psychiatry. 2015;172:52–8.
Mishra BR, Agrawal K, Biswas T, Mohapatra D, Nath S, Maiti R. Comparison of acute followed by maintenance ECT vs clozapine on psychopathology and regional cerebral blood flow in treatment-resistant schizophrenia: a randomized controlled trial. Schizophr Bull. 2022;48:814–25.
Suzuki K, Takano T, Ebina Y, Takamatsu K, Awata S, Matsuoka H. Continuation electroconvulsive therapy to prevent relapse of schizophrenia in relapse-prone patients. J ECT. 2007;23:204–5.
Lévy-Rueff M, Gourevitch R, Lôo H, Olié J-P, Amado I. Maintenance electroconvulsive therapy: an alternative treatment for refractory schizophrenia and schizoaffective disorders. Psychiatry Res. 2010;175:280–3.
Shelef A, Mazeh D, Berger U, Baruch Y, Barak Y. Acute electroconvulsive therapy followed by maintenance electroconvulsive therapy decreases hospital re-admission rates of older patients with severe mental illness. J ECT. 2015;31:125–8.
Krepela J, Hosak L, Pachlova B, Hrdlicka M. Maintenance electroconvulsive therapy in schizophrenia. Psychiatr Danub. 2019;31:62–8.
Isserles M, Remington J, Kaster TS, Daskalakis ZJ, Blumberger DM. Clinical effectiveness of maintenance electroconvulsive therapy in patients with schizophrenia: a retrospective cohort study. J ECT. 2020;36:42–6.
Huuhka K, Viikki M, Tammentie T, Tuohimaa K, Björkqvist M, Alanen H-M, Leinonen E, Kampman O. One-year follow-up after discontinuing maintenance electroconvulsive therapy. J ECT. 2012;28:225–8.
Chanpattana W, Chakrabhand ML. Factors influencing treatment frequency of continuation ECT in schizophrenia. J ECT. 2001;17:190–4.
Agrawal A, Das S, Thirthalli J. When obsessive compulsive disorder responds only to electroconvulsive therapy: a rare case for maintenance electroconvulsive therapy? J Neurosci Rural Pract. 2018;9:450–1.
Husain MM, Lewis SF, Thornton WL. Maintenance ECT for refractory obsessive-compulsive disorder. Am J Psychiatry. 1993;150:1899–900.
Casey DA, Davis MH. Obsessive-compulsive disorder responsive to electroconvulsive therapy in an elderly woman. South Med J. 1994;87:862–4.
Raveendranathan D, Srinivasaraju R, Ratheesh A, Math SB, Reddy YCJ. Treatment-refractory OCD responding to maintenance electroconvulsive therapy. J Neuropsychiatry Clin Neurosci. 2012;24:E16-17.
Bülbül F, Copoglu US, Alpak G, Unal A, Tastan MF, Savas HA. Maintenance therapy with electroconvulsive therapy in a patient with a codiagnosis of bipolar disorder and obsessive-compulsive disorder. J ECT. 2013;29:e21-22.
Hanisch F, Friedemann J, Piro J, Gutmann P. Maintenance electroconvulsive therapy for comorbid pharmacotherapy-refractory obsessive-compulsive and schizoaffective disorder. Eur J Med Res. 2009;14:367–8.
Nilsson BM, Ekselius L. Acute and maintenance electroconvulsive therapy for treatment of severely disabling obsessive-compulsive symptoms in a patient with Asperger syndrome. J ECT. 2009;25:205–7.
Rao NP, Antony A, Raveendranathan D, Venkatasubramanian G, Behere RV, Varambally SS, Gangadhar BN. Successful use of maintenance electroconvulsive therapy in the treatment of clozapine-associated obsessive-compulsive symptoms in schizophrenia: a case report. J ECT. 2011;27:e37-38.
Madero S, Anmella G, Sagué-Vilavella M, et al. Evaluating maintenance electroconvulsive therapy in Bipolar Disorders: 3-year mirror-image study. J Affect Disord. 2022;298:58–64.
Ross EL, Zivin K, Maixner DF. Cost-effectiveness of electroconvulsive therapy vs pharmacotherapy/psychotherapy for treatment-resistant depression in the United States. JAMA Psychiat. 2018;75:713–22.
Fitzgibbon KP, Plett D, Chan BCF, Hancock-Howard R, Coyte PC, Blumberger DM. Cost–utility analysis of electroconvulsive therapy and repetitive transcranial magnetic stimulation for treatment-resistant depression in Ontario. Can J Psychiatry Rev Can Psychiatr. 2020;65:164–73.
Semkovska M, McLoughlin DM. Objective cognitive performance associated with electroconvulsive therapy for depression: a systematic review and meta-analysis. Biol Psychiatry. 2010;68:568–77.
Vothknecht S, Kho KH, van Schaick HW, Zwinderman AH, Middelkoop H, Blansjaar BA. Effects of maintenance electroconvulsive therapy on cognitive functions. J ECT. 2003;19:151–7.
Yoldi-Negrete M, Gill L-N, Olivares S, Lauzière A, Désilets M, Tourjman SV. The effect of continuation and maintenance electroconvulsive therapy on cognition: a systematic review of the literature and meta-analysis. J Affect Disord. 2022;316:148–60.
Kerner N, Prudic J. Current electroconvulsive therapy practice and research in the geriatric population. Neuropsychiatry. 2014;4:33–54.
Rhebergen D, Huisman A, Bouckaert F, Kho K, Kok R, Sienaert P, Spaans H-P, Stek M. Older age is associated with rapid remission of depression after electroconvulsive therapy: a latent class growth analysis. Am J Geriatr Psychiatry. 2015;23:274–82.
•• Lisanby SH, McClintock SM, McCall WV, et al. Longitudinal neurocognitive effects of combined electroconvulsive therapy (ECT) and pharmacotherapy in major depressive disorder in older adults: phase 2 of the PRIDE study. Am J Geriatr Psychiatry. 2022;30:15–28. This was the first report of long-term outcomes with unilateral ECT, followed by M-ECT and pharmacotherapy, in older adults with acute depression. The key finding was that neurocognitive functions improved over a 6-month follow-up period.
van Schaik AM, Comijs HC, Sonnenberg CM, Beekman AT, Sienaert P, Stek ML. Efficacy and safety of continuation and maintenance electroconvulsive therapy in depressed elderly patients: a systematic review. Am J Geriatr Psychiatry. 2012;20:5–17.
Geduldig ET, Kellner CH. Electroconvulsive therapy in the elderly: new findings in geriatric depression. Curr Psychiatry Rep. 2016;18:40.
González-Romero MF, Avina-Galindo AM, Elbe D, Friedlander R, Vila-Rodriguez F. Lifesaving electroconvulsive therapy for a child with autism spectrum disorder, severe self-injurious behavior, and neuroleptic malignant syndrome. J ECT. 2019;35:e55–6.
Wachtel LE, Hermida A, Dhossche DM. Maintenance electroconvulsive therapy in autistic catatonia: a case series review. Prog Neuropsychopharmacol Biol Psychiatry. 2010;34:581–7.
Miles JH, Takahashi N, Muckerman J, Nowell KP, Ithman M. Catatonia in Down syndrome: systematic approach to diagnosis, treatment and outcome assessment based on a case series of seven patients. Neuropsychiatr Dis Treat. 2019;15:2723–41.
Baeza I, Flamarique I, Garrido JM, Horga G, Pons A, Bernardo M, Morer A, Lázaro ML, Castro-Fornieles J. Clinical experience using electroconvulsive therapy in adolescents with schizophrenia spectrum disorders. J Child Adolesc Psychopharmacol. 2010;20:205–9.
Rajkumar MG, Srinivasa RP, Harish P. Concept of electroconvulsive therapy in India: a narrative review. J Clin Biomed Sci. 2023;13:25–8.
O’Reardon JP, Cristancho MA, von Andreae CV, Cristancho P, Weiss D. Acute and maintenance electroconvulsive therapy for treatment of severe major depression during the second and third trimesters of pregnancy with infant follow-up to 18 months: case report and review of the literature. J ECT. 2011;27:e23.
Bozkurt A, Karlidere T, Isintas M, Ozmenler NK, Ozsahin A, Yanarates O. Acute and maintenance electroconvulsive therapy for treatment of psychotic depression in a pregnant patient. J ECT. 2007;23:185–7.
Rabheru K. Maintenance Electroconvulsive Therapy (M-ECT) After acute response: examining the evidence for who, what, when, and how? J ECT. 2012;28:39–47.
Choi KM, Choi S-H, Hong JK, Lee MH, Jung JH, Oh SH, Jung DC, Kim SN. The effects of continuation-maintenance electroconvulsive therapy on reducing hospital re-admissions in patients with treatment-resistant schizophrenia. Clin Psychopharmacol Neurosci. 2018;16:339–42.
Author information
Authors and Affiliations
Contributions
Conceptualization: Vikas Menon; literature search and data analysis: Ilambaridhi Balasubramanian, Bandita Abhijita; writing—original draft preparation: Bandita Abhijita; writing—review and editing: Ilambaridhi Balasubramanian, Vikas Menon. All authors read and approved the final manuscript.
Corresponding author
Ethics declarations
Ethical Approval
Not applicable.
Competing Interests
The authors declare no competing interests.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Balasubramanian, I., Abhijita, B. & Menon, V. Electroconvulsive Therapy as Maintenance Treatment in Psychiatric Disorders. Curr Behav Neurosci Rep 11, 1–13 (2024). https://doi.org/10.1007/s40473-023-00266-3
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40473-023-00266-3