Continuous Antidepressant Treatment Research Articles

Adding online storytelling-based acceptance and commitment therapy to antidepressant treatment for primary care patients: a randomized clinical trial

ABSTRACT Depression is most often treated in primary care, where the prevailing treatment is antidepressant medication. Primary care patients with depression are less likely to be exposed to psychosocial interventions, despite evidence suggesting many of these treatments are effective. An example is acceptance and commitment therapy (ACT), a behavioral treatment for depression with a growing evidence base. A self-guided ACT intervention with a peer narrative (i.e. storytelling) format was developed with the intention of creating a treatment option for primary care patients that was more accessible than traditional psychotherapy. Titled LifeStories, the online program features videos of real individuals sharing coping skills for depression based on lived experiences and key ACT principles. A total of 93 primary care patients taking antidepressants were randomized to either continued antidepressant treatment alone or antidepressant treatment plus LifeStories for 4 weeks. There were no differences over time on depression severity and psychological inflexibility. However, LifeStories led to greater improvements in quality of life and increased patients’ interest in additional treatment compared to antidepressant medication alone.Clinical trial pre-registration: ClinicalTrials.gov (NCT04757961)

Three-Year Prognosis of Late-Life Depression in an Outpatient Geriatric Psychiatry Clinic: Medical Comorbidities Worsen Outcomes.

Depression is one of the most important reasons for psychiatric referrals in elderly patients. Geriatric depression can be chronic and is associated with an increased risk of dementia. We aimed to determine the prognosis of major depression patients and associated risk factors regarding persistence of depression. Patients who were admitted to the tertiary geriatric psychiatric outpatient unit of Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul between January and December 2018 and were diagnosed with major depression according to DSM-5 diagnostic criteria were included in the study. A structured telephone interview was conducted with between February-April 2022. For detailed clinical evaluation, Turkish version of Structured Clinical Interview for DSM-5-Disorders/Clinician Version (SCID-5/CV-TR), Telephone Cognitive Screen (T-cogS-TR), Geriatric Depression Scale (GDS), Clinical Dementia Rating Scale (CDR), Lawton-Brody Instrumental Activities of Daily Living Scale (IADL) and Beck Anxiety Inventory (BAI) were used. Of the 123 patients interviewed, 40.9% were diagnosed with major depression and 14.6% with minor depression. 43.4% showed significant anxiety and depression symptoms. Dementia developed in 14.6% of the patients. Only 29.5% of the patients recovered completely. Hypertension, orthopedic disease or arthritis, cancer, and absence of prior work experience were found to be predictors of current depression diagnosis. Geriatric depression has an unfavorable prognosis despite continued antidepressant treatment and may even serve as a prodrome for future dementia. Timely management of co-morbid medical conditions such as hypertension can potentially improve the prognosis of geriatric depression.

Psychiatric visits during the postpartum year in women with eating disorders who continue or discontinue antidepressant treatment in pregnancy.

To determine the association between continued antidepressant use in pregnancy and postpartum psychiatric visits for eating (ED) or mood/anxiety disorders in women with preexisting ED. Using Danish health registry data (1998-2015), we identified 3529 pregnancies in women with ED prepregnancy: (i) 564 with continued antidepressant use before and during pregnancy; (ii) 778 with discontinued antidepressants before pregnancy; (iii) 2137 unexposed. Outpatient and inpatient postpartum visits for an ED or a mood/anxiety disorder constituted the outcome measures. We estimated hazard ratios (HRs) and 95% confidence intervals (CI) using Cox regression with inverse probability of treatment weighting, and performed stratified analyses by antidepressant prescription filling in the first 3 months postpartum. The weighted cumulative incidence for an ED visit at end of follow-up was 4.5% (continued) and 4.8% (discontinued). We found no association between continued antidepressant and postpartum ED visit, relative to discontinued (HR: 0.89, 95% CI: 0.52-1.52). The HR for postpartum mood/anxiety disorder visit was 1.27 (95% CI: 0.68-2.36) with continued antidepressants versus discontinued but decreased if more than two antidepressant prescriptions were refilled. Continued antidepressant use was associated with a 57% reduced likelihood of a postpartum ED visit versus discontinued use in pregnancies with antidepressant prescription refills in the early postpartum. Among women with preexisting ED, there was no association between continued antidepressant use during pregnancy and the likelihood of postpartum psychiatric visits, relative to discontinued antidepressants before pregnancy. Continuation of treatment into the early postpartum is associated with reduced likelihood of postpartum ED visit. Based on data from the Danish registries, we identified 3529 pregnancies among women with preexisting eating disorders before pregnancy. Women with continued antidepressant treatment both before and during pregnancy did not have a lower probability of having postpartum psychiatric visits for an eating disorder or for mood/anxiety disorders (often coexisting with eating disorders), relative to those who discontinued antidepressants before pregnancy. Further continuation of antidepressant treatment into the early postpartum is associated with improved maternal postpartum outcomes. However, residual confounding by disease severity limits confidence in this conclusion.

State-Independent Microstructural White Matter Abnormalities in Major Depressive Disorder.

BackgroundEven with continuous antidepressant treatment, residual symptoms and the risk of relapse can persist in remitted major depressive disorder (MDD) patients. Hence, having a clear recognition of the persistent abnormalities of the underlying neural substrate in MDD through a longitudinal investigation is of great importance.MethodsA total of 127 adult medication-free MDD patients with an acute depressive episode and 118 matched healthy controls (HCs) underwent diffusion tensor imaging. Over a 6-month treatment course, 62 remitted patients underwent a second scan. Remission was defined as a 24-item Hamilton Depression Rating Scale (HAMD24) score ≤7 for at least two weeks. Diffusion tensor imaging was performed with a 3.0 T scanner. Differences in whole-brain fractional anisotropy (FA) between MDD patients and HCs were assessed by an independent t-test using gender, age, and education as covariates.ResultsSignificant FA reductions in the left insula, left middle occipital gyrus, right thalamus, left pallidum and left precuneus were observed in current MDD (cMDD) patients compared with HCs. Moreover, significant FA reductions in the left insula were observed in remitted (rMDD) patients compared to HCs. However, no significant differences in FA values were found when comparing cMDD and rMDD patients.ConclusionsThe abnormalities in the insula showed state-independent characteristics, while the abnormalities in the middle occipital gyrus, thalamus, pallidum and precuneus seemed to be state-dependent impairments in MDD patients.

Do social functioning and symptoms improve with continuation antidepressant treatment of persistent depressive disorder? An observational study

ObjectiveTo determine efficacy of continued treatment with the serotonin norepinephrine reuptake inhibitor duloxetine on symptom reduction and functional improvement in outpatients with dysthymia. MethodFifty outpatients with DSM-IV-TR diagnosed dysthymia who had participated in a 10 week double-blind, placebo-controlled study of duloxetine received open treatment for three months. Nineteen duloxetine responders continued duloxetine, 24 patients initially treated with placebo started open duloxetine treatment, and 7 duloxetine non-responders were treated with desvenlafaxine or bupropion, selected by clinician choice. ResultsPatients continuing duloxetine maintained symptom improvement, 84% meeting response and 63% remission criteria at week 22. Patients initially treated with placebo showed similarly high levels of response (83%) and remission (62%) at week 22, and most duloxetine non-responders subsequently responded to other antidepressants. Duloxetine-continuation patients improved modestly between weeks 10 and 22 on measures of social and cognitive functioning and temperament. Despite this improvement concurrently across several functional domains, 66.7% of patients continuing duloxetine remained in the impaired range of functioning according to the Social Adjustment Scale (SAS). ConclusionsContinued duloxetine treatment appears to be effective in maintaining symptom response in dysthymic disorder, and has positive effects on social functioning. However, the majority of patients do not show normalization of functioning, even when controlling for remission status. Additional treatments should be considered to target residual impairments in social functioning in mood remitted patients with persistent depressive disorder.

A review of antidepressant-induced urinary hesitancy: a focus on levomilnacipran ER including two case presentations(5633)

ABSTRACTIntroduction: Levomilnacipran ER was recently FDA approved as Fetzima® for the treatment of MDD. Urinary hesitancy can be an adverse event associated with levomilnacipran treatment.Areas covered: This manuscript details the longitudinal course of levomilnacipran-induced urinary hesitancy in 2 cases that were in a pivotal clinical trial, examining possible predisposing factors and treatment issues. This manuscript also reviews the literature comparing urinary hesitancy associated with levomilnacipran versus other antidepressants. Antidepressants that are potent norepinephrine reuptake inhibitors like levomilnacipran, may have increased rates of associated urinary hesitancy. The latter can cause significant discomfort and a compromised quality of life. Occasionally, it can progress to urinary retention necessitating an emergency medical intervention.Expert opinion: All patients being treated with antidepressants should be carefully monitored for this side effect. Discontinuation of treatment or reduction of the dose of antidepressant frequently relieves urinary hesitancy; alternatively, treatment with an alpha1A antagonist, e.g., tamsulosin may relieve antidepressant-induced urinary hesitancy within hours to days; such strategies allow for continued antidepressant treatment without urinary hesitancy recurring. Thus, with appropriate clinical care, the benefits using levomilnacipran outweigh its risks.

Community pharmacists' support improves antidepressant adherence in the community.

The treatment goal of major depressive disorder (MDD) is achieving and maintaining remission. One of the major obstacles in attaining remission is poor adherence to the medication regimen. Community pharmacists (CPs) are accessible to primary care patients and are in a unique position to help improve adherence. The aim was to compare the effectiveness of pharmacist intervention with standard care for patients with MDD. This was an exploratory controlled trial conducted in 17 general pharmacies with clinical pharmacists in Israel. Participants were patients with MDD prescribed escitalopram by their general practitioner. CP medication review was initiated at enrollment, with face-to-face pharmacist adherence support at treatment initiation and every month throughout the study. Treatment as usual (TAU) was derived from computerized medical charts for the same pharmacies during the same time period. Comparison with published 'historical' controls was also carried out. No blinding was possible. Continuous antidepressant treatment at 6 months as reflected in computerized pharmacy records was the primary outcome. Within a 1-year period, 173 patients were enrolled. There were 49 men (28%) and 124 women (72%) in the CP group, mean age 53.9 ± 18.9 years. There were 4079 men (32%) and 8667 women (68%) in the TAU group, mean age 50.4 ± 17.8 years. Ninety-six patients (55%) completed 6 months of antidepressant treatment. At 1 month, the adherence rate was 71% in the CP arm and at 6 months, the rates were 55% versus published norms of 42% (P=0.004). At 1 month, the adherence rate was 57% (N=7256) in the TAU arm and at 6 months, the rate was 15.2% (N=1934) (compared with CP rates: P<0.0001). There were no differences between sites in adherence rates. CPs participating in this study reported higher levels of confidence in supporting MDD patients at the end of the study. This is the first trial of pharmacist adherence support in Israel, and shows benefits for patients in the community with MDD.

The effects of continuous antidepressant treatment during the first 6months on relapse or recurrence of depression

The effects of continuous antidepressant treatment during the first 6months on relapse or recurrence of depression

The effects of continuous antidepressant treatment during the first 6months on relapse or recurrence of depression

To examine whether continuous antidepressant treatment during the first 6 month reduces the risk of relapse/recurrence of depression in South Korea. We used National Health Insurance Data covering the period from 2001 through 2004. The study population consisted of 117,087 adult patients who received antidepressants after being diagnosed with depression. The continuous antidepressant was defined as evidence of antidepressant prescriptions for 75% of the first 6 months of treatment. Relapse or recurrence during the next 18-month period was defined by evidence of a new episode requiring antidepressant treatment, psychiatric hospitalization, electroconvulsive therapy, emergency department visit or attempted suicide. We compared the relapse/recurrence rate during the 18-month follow-up period in patients receiving continuous treatment and those who discontinued early using a Cox's proportional hazard model. Patients receiving continuous antidepressant treatment experienced a lower risk of relapse/recurrence (Hazard ratio: 0.42, 95% CI: 0.40-0.44). Three or more follow-up visits in the first 3 months also reduced the risk of relapse/recurrence. Factors associated with a significant increase of relapse/recurrence were comorbid medical illness, anxiety disorder, and alcohol abuse. The small benefit of SSRIs was appeared only in the early discontinued treatment subgroup, not in the continuous treatment subgroup. We were not able to consider the antidepressant utilization pattern. Continuous antidepressant treatment and frequent follow-up visits during the acute phase were associated with a significant reduction in the likelihood of relapse or recurrence of depression. Our results provide important evidence on the effectiveness of antidepressant treatment in South Korea.

Dr Altshuler Replies

To the Editor: We thank Roger Sparhawk, MD, for his letter and concern regarding the use of antidepressants in patients with bipolar disorder. He is specifically concerned that the findings from our study may be uncritically misapplied by physicians in the community, leading to widespread antidepressant prescribing. We want to underscore that our findings do not address whether antidepressants, in conjunction with a mood stabilizer, should be a first-line standard treatment for patients with bipolar disorder. Rather, our study addresses whether an antidepressant should be continued in patients who do not optimally respond to them in the acute treatment phase. In specific response to Dr Sparhawk’s comments: 1. A prior retrospective study of ours did, in fact, show that only 15% of bipolar patients treated with antidepressants could tolerate a 6-week antidepressant trial, had a positive response, and did not switch into mania. The patients in our current study involved patients who were first in a prospective double-blind, placebo-controlled trial and had either a partial or a positive antidepressant response in that acute treatment trial. In that study, the positive or partial response rate was less than 50% but greater than the 15% in our prior retrospective study. In both studies, however, it is clear that for many patients with bipolar disorder, antidepressants may not be well tolerated or helpful at treating their depression. 2. We agree that it is important to note that our acute partial responders were less likely to further achieve a full positive antidepressant response with continued coadministration of antidepressants than those who had initially achieved a full positive response. In fact, the conclusion of our study is that patients who do not respond fully acutely may not benefit further from continued antidepressant treatment. 3. All of the patients in our study were, in fact, first treated and did not respond to adequate doses or levels of lithium, divalproex sodium, carbamazepine, or an antipsychotic agent prior to the addition of an antidepressant. We regret that the author believes that this standard is not consistently carried out in clinical practice in his geographic area. Further, while atypical antipsychotics certainly have a place in the treatment of patients with bipolar disorder, our study does not address whether an antipsychotic versus a more “classic” mood stabilizer may be differentially beneficial for patients with bipolar depression.

A serotonin transporter gene polymorphism predicts peripartum depressive symptoms in an at-risk psychiatric cohort

Backgroud Peripartum major depressive disorder (MDD) is a prevalent psychiatric disorder with potential detrimental consequences for both mother and child. Despite its enormous health care relevance, data regarding genetic predictors of peripartum depression are sparse. The aim of this study was to investigate associations of the serotonin-transporter linked polymorphic region (5-HTTLPR) genotype with peripartum MDD in an at-risk population. Methods Two hundred and seventy four women with a prior history of MDD were genotyped for 5-HTTLPR and serially evaluated in late pregnancy (gestational weeks 31–40), early post-partum (week 1–8) and late post-partum (week 9–24) for diagnosis of a current major depressive episode (MDE) and depressive symptom severity. Results 5-HTTLPR S-allele carrier status predicted the occurrence of a MDE in the early post-partum period only (OR = 5.13, p = 0.017). This association persisted despite continued antidepressant treatment. Conclusions The 5-HTTLPR genotype may be a clinically relevant predictor of early post-partum depression in an at-risk population. Objective Peripartum major depressive disorder is a prevalent psychiatric disorder with potential detrimental consequences for both mother and child. Despite its enormous health care relevance, data regarding genetic predictors of peripartum depression are sparse. The aim of this study was to investigate associations of the serotonin-transporter linked polymorphic region (5-HTTLPR) genotype with peripartum MDD in an at-risk population.

Treatment response and duration of maintenance treatment with adjunctive antidepressants in bipolar depression: A retrospective chart review

Objective. The aim of this study was to investigate the treatment response and optimal maintenance period of antidepressants to minimize the risk of switching in bipolar depression in clinical practice. Methods. In a retrospective chart review, 78 bipolar patients, treated for a depressive episode by adding antidepressant to ongoing mood-stabilizing medications and had been followed for at least 6 months were identified. We determined recovery to euthymia and/or switching into mania during the 6-month follow-up period and estimated the time from antidepressant initiation to mood change. Results. Antidepressants treatment responses were classified into four groups. In one group, depression was sustained for 6 months despite continuous antidepressant treatment (poor-response group, 10.3%). In the second, abrupt switch into mania occurred during antidepressant treatment (acute-switch group, 19.2%). In the third, the depression improved to euthymia without manic switching (good-response group, 50%). In the fourth, the depression improved to euthymia but manic switching occurred during maintenance with antidepressants (delayed-switch group, 20.5%), and the mean duration of antidepressants maintenance was 54.6±38.9 days. Conclusions. Bipolar depression has heterogeneous treatment responses to adjunctive antidepressant. Antidepressants should be discontinued within 8 weeks after improvement to euthymia to minimize the risk of manic switching.

Antidepressant treatment for depression: total charges and therapy duration*

BACKGROUND: The economic costs of depression are significant, both the direct medical costs of care and the indirect costs of lost productivity. Empirical studies of antidepressant cost-effectiveness suggest that the use of selective serotonin reuptake inhibitors (SSRIs) may be no more costly than tricyclic antidepressants (TCAs), will improve tolerability, and is associated with longer therapy duration. However the success of depression care usually involves multiple factors, including source of care, type of care, and patient characteristics, in addition to drug choice. The cost-effective mix of antidepressant therapy components is unclear. AIMS OF THE STUDY: Our study evaluates cost and antidepressant-continuity outcomes for depressed patients receiving antidepressant therapy. Specifically, we determined the impact of provider choice for initial care, concurrent psychotherapy, and choice of SSRI versus TCA-based pharmacotherapies on the joint outcome of low treatment cost and continuous antidepressant therapy. METHODS: A database of private health insurance claims identifies 2678 patients who received both a diagnosis of depression and a prescription for an antidepressant during 1990-1994. Patients each fall into one of four groups according to whether their health care charges are high versus low (using the median value as the break point) and by whether their antidepressant usage pattern is continuous versus having discontinued pharmacotherapy early (filling fewer than six prescriptions). A bivariate probit model controlling for patient characteristics, co-morbidities, type of depression and concurrent treatment is the primary multivariate statistical vehicle for the cost-effective treatment situation. RESULTS: SSRIs substantially reduce the incidence of patients discontinuing pharmacotherapy while leaving charges largely unchanged. The relative effectiveness of SSRIs in depression treatment is independent of the patient's personal characteristics and dominates the consequences of other treatment dimensions such as seeing a mental health specialist and receiving concurrent psychotherapy. Initial provider specialty is irrelevant to the continuity of pharmacotherapy, and concurrent psychotherapy creates a tradeoff through reduced pharmacotherapy interruption with higher costs. DISCUSSION: Longer therapy duration is associated with SSRI-based pharmacotherapy (relative to TCA-based pharmacotherapy) and with concurrent psychotherapy. High cost is associated with concurrent psychotherapy and choice of a specialty provider for initial care. In our study cost-effective care includes SSRI-based pharmacotherapy initiated with a non-specialty provider. Previous treatment history and other unobserved factors that might affect antidepressant choice are not included in our model. IMPLICATIONS FOR HEALTH CARE PROVISION: The decision to use an SSRI-based pharmacotherapy need not consider carefully the patient's personal characteristics. Shifting depressed patients' pharmacotherapy away from TCAs to SSRIs has the effect of improving outcomes by lowering the incidence of discontinuation of pharmacotherapy while leaving largely unchanged the likelihood of having high overall health care charges. Targeted use of concurrent psychotherapy may be additionally cost-effective. IMPLICATIONS FOR HEALTH POLICIES: The interaction of various components of depression care can alter the cost-effectiveness of antidepressant therapy. Our results demonstrate a role for the non-specialty provider in initiating care and support increased use of SSRIs as first-line therapy for depression as a way of providing cost-effective care that is consistent with APA guidelines for continuous antidepressant treatment. IMPLICATIONS FOR FURTHER RESEARCH: Further research that improves our understanding of how decisions regarding provider choice, concurrent psychotherapy, and drug choice are made will improve our understanding of the effects treatment choices on the cost-effectiveness of depression care. We have suggested that targeted concurrent psychotherapy may prove to be cost-effective; research to determine groups most likely to benefit from the additional treatment would further enable clinicians and healthcare policy makers to form a consensus regarding a model for treating depression.

Antidepressant treatment for depression: total charges and therapy durationSource of funding: Research funded by Eli Lilly and Company. Drs. Croghan, Melfi, and Obenchain are employees and stockholders of Eli Lilly and Company. The study was performed while Dr. Kniesner was a Visiting Research Fellow at Eli Lilly and Company. It was also performed in partial fulfillment of the requirements for

Background: The economic costs of depression are significant, both the direct medical costs of care and the indirect costs of lost productivity. Empirical studies of antidepressant cost-effectiveness suggest that the use of selective serotonin reuptake inhibitors (SSRIs) may be no more costly than tricyclic antidepressants (TCAs), will improve tolerability, and is associated with longer therapy duration. However the success of depression care usually involves multiple factors, including source of care, type of care, and patient characteristics, in addition to drug choice. The cost-effective mix of antidepressant therapy components is unclear. Aims of the Study: Our study evaluates cost and antidepressant-continuity outcomes for depressed patients receiving antidepressant therapy. Specifically, we determined the impact of provider choice for initial care, concurrent psychotherapy, and choice of SSRI versus TCA-based pharmacotherapies on the joint outcome of low treatment cost and continuous antidepressant therapy. Methods: A database of private health insurance claims identifies 2678 patients who received both a diagnosis of depression and a prescription for an antidepressant during 1990–1994. Patients each fall into one of four groups according to whether their health care charges are high versus low (using the median value as the break point) and by whether their antidepressant usage pattern is continuous versus having discontinued pharmacotherapy early (filling fewer than six prescriptions). A bivariate probit model controlling for patient characteristics, co-morbidities, type of depression and concurrent treatment is the primary multivariate statistical vehicle for the cost-effective treatment situation. Results: SSRIs substantially reduce the incidence of patients discontinuing pharmacotherapy while leaving charges largely unchanged. The relative effectiveness of SSRIs in depression treatment is independent of the patient's personal characteristics and dominates the consequences of other treatment dimensions such as seeing a mental health specialist and receiving concurrent psychotherapy. Initial provider specialty is irrelevant to the continuity of pharmacotherapy, and concurrent psychotherapy creates a tradeoff through reduced pharmacotherapy interruption with higher costs. Discussion: Longer therapy duration is associated with SSRI-based pharmacotherapy (relative to TCA-based pharmacotherapy) and with concurrent psychotherapy. High cost is associated with concurrent psychotherapy and choice of a specialty provider for initial care. In our study cost-effective care includes SSRI-based pharmacotherapy initiated with a non-specialty provider. Previous treatment history and other unobserved factors that might affect antidepressant choice are not included in our model. Implications for Health Care Provision: The decision to use an SSRI-based pharmacotherapy need not consider carefully the patient's personal characteristics. Shifting depressed patients' pharmacotherapy away from TCAs to SSRIs has the effect of improving outcomes by lowering the incidence of discontinuation of pharmacotherapy while leaving largely unchanged the likelihood of having high overall health care charges. Targeted use of concurrent psychotherapy may be additionally cost-effective. Implications for Health Policies: The interaction of various components of depression care can alter the cost-effectiveness of antidepressant therapy. Our results demonstrate a role for the non-specialty provider in initiating care and support increased use of SSRIs as first-line therapy for depression as a way of providing cost-effective care that is consistent with APA guidelines for continuous antidepressant treatment. Implications for Further Research: Further research that improves our understanding of how decisions regarding provider choice, concurrent psychotherapy, and drug choice are made will improve our understanding of the effects treatment choices on the cost-effectiveness of depression care. We have suggested that targeted concurrent psychotherapy may prove to be cost-effective; research to determine groups most likely to benefit from the additional treatment would further enable clinicians and healthcare policy makers to form a consensus regarding a model for treating depression. Copyright © 2000 John Wiley & Sons, Ltd.

Social adjustment does not predict depressive relapse during continuation fluoxetine therapy

The purpose of this study was to assess the relationship between social adjustment and the risk of depressive relapse during continuation antidepressant treatment. The Social Adjustment Scale-Self Report Version (SAS-SR) was used to assess a broad range of social functioning before and after acute treatment in 41 outpatients with unipolar depression who responded to fluoxetine and then continued on this antidepressant. No differences were detected between those who relapsed and those who stayed well with regard to pre- and posttreatment SAS-SR total or subscale scores. These data suggest that social functioning does not affect the risk of relapse while depressed patients are taking fluoxetine continuation treatment.

Relapse after successful electroconvulsive therapy: The use and impact of continuation antidepressant drug treatment

AbstractThirty eight (76 per cent) of a series of 50 depressed patients routinely referred for bilateral electroconvulsive therapy (ECT) improved markedly by two weeks after the last ECT. Patients remained under the care of their responsible clinicians after ECT. Only one‐third of the patients who improved markedly were prescribed continuation antiddepressant drug treatment for at least four months after ECT. Seventeen (46 per cent) of the patients who improved relapsed within six months of the last ECT. Patients who did not receive continuation antidepressant drug treatment were four times more likely to relapse (the 95 per cent confidence interval of the excess relapse rate was 24 to 78 percent).