REVIEW OF: Jørgensen A et al, JAMA Psychiatry 2024;81(12):1207–1214

STUDY TYPE: Retrospective observational study

Despite the effectiveness of ECT for acute psychiatric episodes, preventing relapse after treatment represents a major clinical challenge. While we often rely on medications to sustain remission, continuation and maintenance ECT (c/mECT) may offer an alternative approach. Despite its potential, there’s been little large-scale research on its real-world efficacy or cost-effectiveness—until now.

This Danish cohort study followed 19,944 patients who received ECT from 2003 to 2022. Among them, 1,533 patients (7.7%) received c/mECT, most frequently those with schizophrenia (odds ratio [OR] 2.1) or schizoaffective disorder (OR 2.4). Patients with unipolar depression were less likely to receive c/mECT (OR 0.6).

The study defined continuation ECT (cECT) as treatments within 180 days of the acute series (aECT), spaced 7–90 days apart, and maintenance ECT (mECT) as ongoing treatments beyond that time frame with similar intervals. Researchers tracked outcomes such as hospitalization and suicidal behavior during the year following ECT, while also analyzing the financial impact by comparing hospital stays and treatment costs. They controlled for diagnoses, medication history, and sociodemographic factors.

Patients receiving c/mECT showed a clear advantage. Hospitalizations dropped significantly, with a 32%–49% reduced risk compared to those treated with aECT alone. This protective effect was especially pronounced in the first six months. Financially, c/mECT proved its value by reducing overall costs, largely by preventing costly hospital readmissions.

On the downside, c/mECT didn’t show a meaningful impact on suicide prevention during the study period. Despite this, its ability to curb relapses and cut costs makes it a valuable option for patients with severe and treatment-resistant psychiatric conditions. The study had some limitations, including the lack of randomized controls, which introduces the possibility of selection bias.

Carlat Take
This study makes a strong case for using c/mECT to keep patients in remission after acute ECT, especially those with difficult-to-treat conditions like schizophrenia or severe psychiatric illnesses that haven’t responded well to medications. Although the study had some limitations, the large sample size lends weight to the findings. If c/mECT isn’t already on your radar for your most challenging cases, it’s worth reconsidering.