CONTINUATION PHARMACOTHERAPY FOLLOWING ECT

电休克疗法(ECT)是一种非常有效的治疗方法 重度抑郁症和接受这种治疗的患者经常出现 患有这种疾病最严重、最反复发作的形式。也许是最多的 ECT领域面临的关键临床问题是早期诊断问题 旧病复发。在对ECT有反应的单相患者中，电流 实践的标准是使用三环类抗抑郁药(TCA)继续 在预防复发方面的治疗。这种做法很大程度上是基于 年在英国进行的三项对照试验的结果 上世纪60年代的S。除了严重的方法缺陷外，这些 对当前实践的研究是值得怀疑的。在这项早期工作中，ECT是 经常被用作‘首选’治疗和适当的标准 在这段时间里，药物治疗发生了很大的变化。在……里面 目前的做法是，对足够的抗抑郁药试验产生抗药性 药物治疗是ECT和耐药的主要适应症 患者构成了ECT样本的很大比例。因此，它是 通常用于ECT后的继续治疗 患者在治疗过程中失败的抗抑郁药物 急性发作。这种做法的有效性从未得到证实。 事实上，在一项初步的前瞻性自然主义研究中，我们发现 失败一次或多次的患者的复发率是前者的两倍 与接受ECT治疗的患者相比，ECT前进行了充分的TCA试验 而没有接受足够的药物试验。ECT术后TCA的充分性 药物治疗与复发率只有轻微的关系， 受益的患者似乎只是那些没有失败的患者 在ECT前进行充分的抗抑郁治疗。在相关研究中，我们 还发现，药物耐药性似乎是一个强有力的预测因素 电击治疗结果。在ECT前未能通过充分的TCA试验的患者 较低的ECT应答率。在这里，我们建议重新评估 ECT应答者的持续药物治疗。在一项多中心试验中， 涉及载体基金会，纽约州精神病研究所，以及 西方精神病学研究所和临床，平行分组，随机 赋值时，采用双盲设计建立相关系数 安慰剂、去甲替林及去甲替林锂联合用药的疗效 碳酸盐延续疗法在预防单相患者复发中的作用 对ECT有反应的患者。据推测，去甲替林 单独或与锂联合治疗对无锂的患者有效 有记录的药物耐药性，但只有组合 继续治疗对失败的患者是有效的。 或在ECT前进行更多的环状抗抑郁药试验。此外，a 将对更大样本的患者进行前瞻性评估 临床特点和治疗史，并对ECT进行标准化 跨站点管理。这一假设将得到检验，即药物治疗 耐药性也是ECT疗效的一个强有力的预测因素，并且，当 考虑到，对更好的ECT的明显关联负责 抑郁症精神病患者的反应。

Electroconvulsive therapy (ECT) is an extremely effective treatment for major depression and patients that receive this modality frequently present with the most severe, recurrent forms of this illness. Perhaps the most critical clinical issue facing the field of ECT is the problem of early relapse. In unipolar patients who have responded to ECT, the current standard of practice is to use tricyclic antidepressant (TCA) continuation therapy in the prevention of relapse. This practice is based largely on the findings of three controlled trials that were conducted in England in the 1960's. Besides serious methodological flaws, the relevance of these studies to present practice is questionable. In this early work, ECT was frequently used as a 'first-choice' treatment and standards for adequate pharmacological treatment have changed considerably over this period. In current practice, resistance to adequate trials of antidepressant medications is a primary indication for ECT and medication-resistant patients form a large proportion of ECT samples. Consequently, it is common to use as continuation therapy following ECT the very same class of antidepressant medications that patients failed during treatment of the acute episode. The efficacy of this practice has never been substantiated. Indeed, in a preliminary prospective, naturalistic study, we found that the relapse rate was twice as high in patients who had failed one or more adequate TCA trials prior to ECT, compared to patients who came to ECT without receiving an adequate medication trial. Adequacy of postECT TCA pharmacotherapy was only marginally related to relapse rates, with the patients who benefited appearing to be only those who had not failed adequate antidepressant treatment prior to ECT. In related research, we have also found that medication resistance appears to be a strong predictor of ECT outcome. Patients who failed adequate TCA trials prior to ECT had a lower ECT response rate. Here we propose to re-evaluate the utility of continuation pharmacotherapy in ECT responders. In a multi-center trial, involving the Carrier Foundation, New York State Psychiatric Institute, and Western Psychiatric Institute and Clinic, a parallel group, random assignment, double-blind design will be used to establish the relative efficacies of placebo, nortriptyline, and combination nortriptyline-lithium carbonate continuation therapies in the prevention of relapse in unipolar patients following response to ECT. It is hypothesized that nortriptyline alone or its combination with lithium will be effective in patients without documented medication resistance, but that only the combination continuation treatment will be efficacious in patients who have failed one or more trials of a cyclic antidepressant prior to ECT. In addition, a larger sample of patients will be prospectively evaluated with respect to clinical features and treatment history, with standardization of ECT administration across sites. The hypothesis will be tested that medication resistance is also a potent predictor of ECT efficacy, and, when considered, is responsible for the apparent association of better ECT response in depressed patients with psychosis.