CONTINUATION PHARMACOTHERAPY FOLLOWING ECT

电休克治疗（ECT）是一种非常有效的治疗方法， 重度抑郁症和接受这种方式的患者经常出现 最严重的复发性疾病 也许最 ECT领域面临的关键临床问题是早期的问题， 复发 在对ECT有反应的单极患者中， 实践标准是使用三环类抗抑郁药（TCA）持续 预防复发的治疗。 这种做法主要是基于 年在英国进行的三项对照试验的结果 1960年代 除了严重的方法论缺陷， 目前的研究实践是值得怀疑的。 在这项早期工作中，ECT是 经常被用作“首选”治疗和标准， 在此期间，药物治疗发生了很大变化。 在 目前的做法，抗抑郁药充分试验的阻力 药物是ECT的主要适应症， 患者构成ECT样品的大部分。 根据该结果 通常用作ECT后的延续治疗，与同类治疗相同 抗抑郁药物，患者在治疗过程中失败， 急性发作 这种做法的效力从未得到证实。 事实上，在一项初步的前瞻性自然主义研究中，我们发现， 在一次或多次治疗失败的患者中，复发率高出两倍。 与接受ECT治疗的患者相比，在ECT治疗前进行了充分的TCA试验 没有接受充分的药物试验。 ECT后TCA的准确性 药物治疗与复发率仅轻微相关， 受益的患者似乎只是那些没有失败的患者， 在ECT之前进行适当的抗抑郁治疗。 在相关研究中，我们 他们还发现，耐药性似乎是一个强有力的预测因素， ECT的结果。 在ECT之前进行充分TCA试验失败的患者， ECT应答率较低。 在这里，我们建议重新评估的效用 ECT应答者的持续药物治疗。 在多中心试验中， 包括开利基金会，纽约州立精神病研究所， 西方精神病研究所和诊所，平行组，随机 分配，双盲设计将用于建立相对 安慰剂、去甲替林和去甲替林-锂联合治疗的疗效 碳酸盐持续治疗在预防单极复发中的作用 对ECT有反应的患者。 假设去甲替林 单独使用或与锂联合使用对没有锂的患者有效 记录了药物耐药性，但只有联合用药 持续治疗将有效的病人谁失败了一个 或在ECT之前进行更多的周期性抗抑郁药试验。 另外还有按 将前瞻性评价更大样本的患者， 临床特征和治疗史，ECT标准化 跨站点管理。 假设将被验证，药物治疗 耐药性也是ECT疗效的一个有力预测因素，当 被认为是负责更好的ECT的明显关联 抑郁症患者对精神病的反应。

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 benefitted 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.