Received Maintenance Electroconvulsive Therapy Research Articles

Maintenance Electroconvulsive Therapy in Catatonia: Clinical Profiles From a Case Series.

This study aims to conduct a descriptive analysis of the clinical features and treatment responses in 6 patients with catatonia who received maintenance electroconvulsive therapy (ECT). Our study included all patients who underwent maintenance ECT (mECT) at the Hospital Clínic de Barcelona between September 2020 and September 2022 following a catatonic episode. The study cohort comprised 5 patients with schizophrenia and 1 patient with major depressive disorder. Among patients with schizophrenia, the first catatonic episode occurred several years after their initial paranoid psychotic episode, whereas the patient with depression experienced a rapid progression from the first depressive episode to catatonia. After acute ECT, 4 patients achieved complete symptomatic remission, 1 patient exhibited a partial response, and another maintained a severe catatonic state. Maintenance ECT was indicated because of the high risk of severe relapses. The mean frequency of mECT sessions was 9.83 (SD, 5.60) days. Notably, 66.67% of the patients were concurrently receiving clozapine as part of their pharmacological treatment. Among patients with schizophrenia, mECT sessions could not be extended beyond 7 to 10 days, whereas the depressed patient could space ECT sessions up to 21 days without experiencing a relapse. Maintenance ECT proves to be a safe and well-tolerated strategy for preventing relapses in severe catatonic patients who have previously stabilized with acute ECT. Further research is needed to develop clinical guidelines that define optimal application strategies for mECT in catatonia.

P179: Clinical characteristics and potential link to Parkinson’s disease and dementia with Lewy bodies in patients with major depressive disorder who received maintenance ECT

Introduction:Maintaining remission after electroconvulsive therapy (ECT) is of clinical relevance in patients with depression, and maintenance ECT is introduced in patients who fail to maintain remission after ECT. However, the clinical characteristics and the biological background of patients who receive maintenance ECT are barely understood.Methods:At Keio University Hospital, Patients with major depressive disorder according to DSM-IV who received ECT between January 2012 and March 2019 followed by maintenance ECT (mECT group) and those who did not (aECT group) were included. Clinical characteristics including the results of neuroimaging marker for Parkinson’s disease and dementia with Lewy bodies were compared between groups.Results:Thirteen and one hundred forty-six patients were included in mECT and aECT groups, respectively. Compared with aECT group, the age of onset and the age of the first ECT was older in mECT group. Besides, mECT group showed significantly higher prevalence of melancholic feature (92.3% vs. 27.4%, p<0.001) and catatonic feature (46.2% vs. 9.6%, p=0.002). The results of neuroimaging marker obtained in 123I-metaiodobenzylguanidine scintigraphy and dopamine transporter scan revealed that 5 of 13 patients and 16 of 146 patients showed Parkinson’s disease and dementia with Lewy bodies in mECT and aECT groups, respectively.Conclusion:Patients who underwent acute and maintenance ECT have impaired dopamine function. Investigating the neurobiology of patients who receiving maintenance ECT is an important area for development of appropriate treatment for depression.

Clinical characteristics and potential association to Parkinson’s disease and dementia with Lewy bodies in patients with major depressive disorder who received maintenance electroconvulsive therapy: a retrospective chart review study

BackgroundMaintaining remission after electroconvulsive therapy (ECT) is clinically relevant in patients with depression, and maintenance ECT has been introduced in patients who fail to maintain remission after ECT. However, the clinical characteristics and biological background of patients who receive maintenance ECT are poorly understood. Thus, this study aimed to examine the clinical background of patients who underwent maintenance ECT.MethodsPatients with major depressive disorder who underwent ECT followed by maintenance ECT (mECT group) and those who did not (acute ECT [aECT] group) were included. Clinical characteristics, including the results of neuroimaging examinations for Parkinson’s disease (PD) and dementia with Levy body (DLB) such as myocardial 123I-metaiodobenzylguanidine (MIBG) scintigraphy and dopamine transporter imaging single-photon emission computerized tomography (DaT-SPECT), were compared between the groups.ResultsIn total, 13 and 146 patients were included in the mECT and aECT groups, respectively. Compared to the aECT group, the mECT group showed a significantly higher prevalence of melancholic features (92.3% vs. 27.4%, p < 0.001) and catatonic features (46.2% vs. 9.6%, p = 0.002). Overall, 8 of the 13 patients in the mECT group and 22 of the 146 patients in the aECT group underwent neuroimaging examinations for PD/DLB. The rate of patients examined is significantly higher in the mECT group than in the aECT group (61.5% vs. 11.2%, p < 0.001). Among the groups examined, 7/8 patients in the mECT group and 16/22 patients in the aECT group showed relevant neuroimaging findings for PD/DLB; the positive rate was not significantly different between the two groups (87.5% vs. 72.7%, p = 0.638).ConclusionsPatients who receive acute and maintenance ECT may have underlying neurodegenerative diseases, including PD/DLB. Investigating the neurobiology of patients who receive maintenance ECT is important for developing appropriate treatments for depression.

Maintenance ECT treatment in New Zealand: Local and national data.

To retrospectively analyse patients receiving maintenance Electroconvulsive therapy (ECT), patterns of ECT treatment administration and impact on hospitalisation before and during treatment, in a single New Zealand District Health Board catchment. We also asked other District Health Boards in New Zealand for annual data on their use of maintenance ECT. Regional analysis: retrospective analysis of patient-level data over 9 years. National analysis: survey of maintenance ECT/year. Regionally, 14 patients received maintenance ECT over 9 years. Patients were 50% male, with mean age 59 years, and principal diagnoses included schizophrenia, bipolar disorder and major depressive disorder. The time between ECT treatments tended to be shorter for patients with schizophrenia compared with those with mood disorders. Duration of time in hospital during maintenance ECT, compared with pre-ECT, was reduced by 52% for all patients, with greater reductions for patients with mood disorders compared with those with schizophrenia. Nationally, 19.7% of all ECT treatments in New Zealand (range 4-57%) were for maintenance treatment. Regional and national use patterns of maintenance ECT in New Zealand resemble those reported internationally. The RANZCP section of neurostimulation is planning ECT standards which would assist with ensuring coherence and quality of High-dose contrast-enhanced computed tomography/modified electroconvulsive therapy practice in New Zealand.

Vagus nerve stimulation in patients receiving maintenance therapy with electroconvulsive therapy: a series of 10 cases

OBJECTIVES Electroconvulsive therapy (ECT) is a mainstay in both acute and long-term management of difficult-to-treat depression. However, frequent acute courses of ECT or prolonged maintenance ECT treatment may increase adverse-effect burden and/or reduce patient acceptability. Therefore, we investigated the effectiveness of adjunctive vagus nerve stimulation (VNS) therapy as an alternative strategy for long-term maintenance treatment in ECT-responsive patients. METHODS This retrospective chart review identified maintenance ECT patients with unipolar (n = 5) and bipolar depression (n = 5) from 2 large hospital systems who had a history of ECT response, but the patients had significant residual incapacitating symptoms or increasing concerns regarding the burden associated with ECT and opted to receive adjunctive VNS therapy. The patients were followed for 2 years after VNS implantation. Response and remission were defined as Clinical Global Impression-Severity scale scores of ≤2 and 1, respectively, obtained at 1- and 2-year postimplantation compared with just before VNS implantation. RESULTS One-year postimplantation, 6 of 10 had responded of which 5 met remission criteria. All 10 patients benefited from adjunctive VNS therapy with either fewer hospitalizations and/or ECT sessions. Seven of 10 stopped maintenance ECT by the end of year 1; an additional patient stopped maintenance ECT by year 2. No patients required an acute course of ECT during the 2-year follow-up. There was a statistically significant reduction (P < 0.0001) in mean (SD) Clinical Global Impression-Severity scale scores between baseline (5.4 [0.51]) and the 1-year postimplantation (2.1 [1.37]) time points, and between baseline and the 2-year postimplantation (2.3 [1.16]) time points, whereas no difference existed between the 1- and 2-year postimplantation time points. CONCLUSIONS Vagus nerve stimulation therapy may be a useful maintenance strategy in patients with difficult-to-treat depression receiving maintenance ECT.

Original Research Article_A retrospective analysis of stimulus characteristics, clinical profile and cognition of patients receiving maintenance electroconvulsive therapy

Original Research Article_A retrospective analysis of stimulus characteristics, clinical profile and cognition of patients receiving maintenance electroconvulsive therapy

Vagus Nerve Stimulation in Patients Receiving Maintenance Therapy With Electroconvulsive Therapy: A Series of 10 Cases.

Electroconvulsive therapy (ECT) is a mainstay in both acute and long-term management of difficult-to-treat depression. However, frequent acute courses of ECT or prolonged maintenance ECT treatment may increase adverse-effect burden and/or reduce patient acceptability. Therefore, we investigated the effectiveness of adjunctive vagus nerve stimulation (VNS) therapy as an alternative strategy for long-term maintenance treatment in ECT-responsive patients. This retrospective chart review identified maintenance ECT patients with unipolar (n = 5) and bipolar depression (n = 5) from 2 large hospital systems who had a history of ECT response, but the patients had significant residual incapacitating symptoms or increasing concerns regarding the burden associated with ECT and opted to receive adjunctive VNS therapy. The patients were followed for 2 years after VNS implantation. Response and remission were defined as Clinical Global Impression-Severity scale scores of ≤2 and 1, respectively, obtained at 1- and 2-year postimplantation compared with just before VNS implantation. One-year postimplantation, 6 of 10 had responded of which 5 met remission criteria. All 10 patients benefited from adjunctive VNS therapy with either fewer hospitalizations and/or ECT sessions. Seven of 10 stopped maintenance ECT by the end of year 1; an additional patient stopped maintenance ECT by year 2. No patients required an acute course of ECT during the 2-year follow-up. There was a statistically significant reduction (P < 0.0001) in mean (SD) Clinical Global Impression-Severity scale scores between baseline (5.4 [0.51]) and the 1-year postimplantation (2.1 [1.37]) time points, and between baseline and the 2-year postimplantation (2.3 [1.16]) time points, whereas no difference existed between the 1- and 2-year postimplantation time points. Vagus nerve stimulation therapy may be a useful maintenance strategy in patients with difficult-to-treat depression receiving maintenance ECT.

Augmentation of clozapine with ECT: a retrospective case analysis.

We sought to assess the effectiveness of clozapine augmentation with Electroconvulsive therapy (ECT) (C+ECT) in patients with clozapine-resistant schizophrenia. We conducted a retrospective review of electronic health records to identify patients treated with C+ECT. We determined the response to C+ECT and the rate of rehospitalisation over the year following treatment with C+ECT. Forty-two patients were treated with C+ECT over a 10-year period. The mean age of the patients at initiation of ECT was 46.3 (SD = 8.2) years (range 27-62 years). The mean number of ECTs given was 10.6 (SD = 5.3) (range 3-25) with the majority receiving twice weekly ECT. Seventy-six per cent of patients (n = 32) showed a Clinical Global Impression-Improvement (CGI-I) score of ≤3 (at least minimally improved) following C+ECT. The mean number of ECT treatments was 10.6 (SD = 5.3) (range 3-25) with the majority receiving twice weekly ECT. Sixty-four per cent of patients experienced no adverse events. Response to C+ECT was not associated with gender, age, duration of illness or duration of clozapine treatment. Seventy-five per cent of responders remained out of hospital over the course of 1-year follow-up, while 70% of those with no response to C+ECT were not admitted to hospital. Three patients received maintenance ECT, one of whom was rehospitalised. This study lends support to emerging evidence for the effectiveness of C+ECT in clozapine-resistant schizophrenia. These results are consistent with the results of a meta-analysis and the only randomised controlled trial (RCT) of this intervention. Further RCTs are required before this treatment can be confidently recommended.

Successful Maintenance

Abstract. This article presents a challenging case of a 64-year-old female with treatment-resistant major depressive disorder with psychotic features and complex medical conditions, including the presence of a cardiac rhythm management device (CRMD). Despite all the complexities, she has received maintenance electroconvulsive therapy (M-ECT) over the past 4 years (56 episodes to date). Her anesthetic plan had to be tailored to her individual needs and revisited to reflect her medical conditions and perioperative complications during this period. Despite the anesthetic challenges, her psychiatric condition improved significantly, and the benefits of her M-ECT continue to outweigh the potential perioperative risks. The successful management of this patient can be attributed to the collaborative involvement and ongoing efforts of a multidisciplinary team that includes psychiatry, anesthesiology, cardiology, and theater and ward nursing personnel. We outline the ongoing challenges with the M-ECT, namely, treatment intervals, medical comorbidities, and the anesthesia management in the presence of a CRMD at a tertiary state hospital in South Africa.

A Pilot Study of Cognitive Impairment in Longstanding Electroconvulsive Therapy-treated Schizophrenia Patients Versus Controls.

Electroconvulsive therapy (ECT), though reliable and effective, is controversial due to its media portrayal as a treatment with severe side effects. Electroconvulsive therapy is mainly given to patients suffering from affective disorders and treatment-resistant schizophrenia. Although past research assessed the amount and duration of memory loss due to ECT, little is known about its influence on cognition for patients suffering from schizophrenia, whose cognitive decline is an inherent part of their illness. We aimed to test whether maintenance ECT causes cognitive decline among elderly schizophrenia patients. Twenty elderly (age >65 years) patients suffering from schizophrenia and schizoaffective disorder who received maintenance ECT were matched with 20 controls suffering from the same illnesses that have never been treated with ECT. The match was based on age, sex, and illness duration. The participants were evaluated using the Montreal Cognitive Assessment for cognitive decline and a Positive and Negative Syndrome Scale (PANSS) for illness severity. A lower score in the abstraction subscale was found in the maintenance ECT population (P = 0.002), without significant differences in the total Montreal Cognitive Assessment and the delayed-recall subscale scores. In the treatment group, a correlation was found between an impairment in naming and positive symptoms in the PANSS score (r = -0.45) and between abstraction impairment and negative symptoms (r = -0.56) and total PANSS score (r = -0.497). Maintenance ECT does not worsen existing global cognitive deficits or delayed recall in elderly schizophrenia patients. The abstraction impairment was possibly due to the higher disease burden of the patients referred to ECT.

Combination of Electroconvulsive Therapy and Clozapine in Treatment-Resistant Schizophrenia

ObjectiveThis study aimed to investigate the effectiveness and tolerability of the combination of electroconvulsive therapy (ECT) in patients with clozapine-treated schizophrenia. MethodsPatients with clozapine-treated schizophrenia during five years of pre-determined period were recruited from Electronic Medical Record. Clinical effects of acute ECT on psychotic symptoms were investigated. We also tried to identify predictive variables requiring maintenance treatment of ECT. ResultsFourteen patients received ECT and clozapine and sixteen were treated with clozapine alone. In the ECT group, which could be refined as clozapine-resistance, PANSS total score was significantly reduced by 19.0±9.9 points, corresponding to a reduction rate of 18.5±8.3%. The clinical remission defined as 20% PANSS reduction criteria was achieved at 42.9%. The subscale factors were significantly reduced, among which the negative symptom was the least. There was no difference in demographic and clinical information between patients receiving and not receiving maintenance ECT, and not all patients seemed to need maintenance ECT if clozapine is continued. ConclusionCombination of ECT and clozapine in patients with clozapine-resistant schizophrenia resulted in a rapid and substantial reduction of psychotic symptoms. Further studies are needed to improve the effectiveness and tolerability of ECT.

Temporal lobe epilepsy following maintenance electroconvulsive therapy-Electrical kindling in the human brain?

Maintenance electroconvulsive therapy (ECT) is sometimes prescribed for refractory psychiatric conditions. We describe five patients who received maintenance ECT and developed florid temporal epileptiform abnormalities on electroencephalography (EEG) despite no history of epilepsy and normal neuroimaging. All patients had received regular ECT for at least 8 months. Three patients had clinical events consistent with epileptic seizures, and video-EEG monitoring captured electrographic seizures in two patients. After cessation of ECT the EEGs normalized in all patients, and no further clinical seizures occurred. Maintenance ECT may predispose to epilepsy with a seizure focus in the temporal lobe.

Mirror-Image Study of Maintenance Electroconvulsive Therapy.

Electroconvulsive therapy (ECT) is a technique with proven efficacy in the treatment of severe psychiatric disorders. However, studies regarding its use as a maintenance therapy are scarce. The aim of the present study was to build knowledge in this area. Data from 28 patients receiving maintenance ECT (M-ECT) were retrospectively collected and analyzed using a mirror-image design. Length of stay and readmissions were compared before M-ECT (control condition) and after M-ECT (experimental condition). Our results showed a decrease in both length of stay and number of readmissions after M-ECT, although the decrease in readmissions was moderated by a site effect. The present study results reveal the potential benefit of M-ECT. Further studies are urgently needed to establish its usefulness as an alternative treatment for severe psychiatric disorders.

Comparison of Clinical Characteristics of Patients on whom Electroconvulsive Therapy was Applied as Inpatient and Outpatient

Objective: Electroconvulsive therapy (ECT) is an efficient and reliable somatic treatment used to treat severe mental disorders. ECT procedure is generally performed by hospitalizing the patient in our country (Turkey). However, there is no obligation to perform ECT by hospitalization, as ECT may be performed without hospitalizing the patient. Outpatient ECT gradually increases during acute and maintenance treatment. Outpatient ECT provides some advantages, such as reduced disruption in social and professional functionality and decrease in treatment costs. Studies that compare acute outpatient ECT and ECT applied after hospitalization are limited. In the present study, we aimed to review clinical characteristics of acute ambulatory ECT and ECT applied by hospitalization comprehensively and retrospectively. Methods: Inpatients and outpatients that received ECT in the Psychiatry Clinic of Dicle University between 2011 and 2014 were enrolled in the present study. Patients’ files between aforementioned years were reviewed retrospectively and data including patient age, gender, diagnosis according to DSM system, hospitalization period, whether ECT was applied, number of ECT sessions, and whether ECT was performed as an inpatient or outpatient procedure were recorded. For the patients who were hospitalized multiple times, each hospitalization was regarded as a different patient and data were assessed independently. For the outpatients who received ECT, all separate ECT sessions were added and ECT count was determined. Those who received maintenance ECT sessions were not included in the outpatient ECT group. Patients who received ECT by acute referral as outpatients were included in this group. Results: Between 2011 and 2014, 904 patients were admitted to the Psychiatry Clinic of Dicle University, Faculty of Medicine , of which 138 received ECT treatment. We also included in the study an additional 38 outpatients who received acute ECT. Inpatients of our clinic in application to ECT were rates of 15.3%. There was no statistically significant difference detected between age, number of ECT sessions applied, diagnosis, and gender of admitted inpatients and outpatients (p>0.05). Conclusions: In our study clinical characteristics of inpatients and outpatients subjects who admitted in order to practiced the ECT were determined to be similar. We believe that an efficient treatment method may be presented to the patients by including acute outpatient ECT more frequently in the treatment plan from physicians.

Electroconvulsive therapy in adolescents with intellectual disability and severe self-injurious behavior and aggression: a retrospective study

Efficacious intervention for severe, treatment-refractory self-injurious behavior and aggression (SIB/AGG) in children and adolescents with intellectual disability and concomitant psychiatric disorders remains a complex and urgent issue. The aim of this study is to assess the efficacy of electroconvulsive therapy (ECT) on severe and treatment-resistant SIB/AGG in young people with intellectual disability and current psychiatric disorder. We reviewed the charts of all patients (N=4) who received ECT in the context of SIB/AGG with resistance to behavioral interventions, milieu therapy and pharmacotherapy from 2007 to 2011. We scored the daily rate of SIB/AGG per patient for each hospital day. Inter rater reliability was good (intraclass correlations=0.91). We used a mixed generalized linear model to assess whether the following explanatory variables (time, ECT) influenced the course of SIB/AGG over time, the dependant variable. The sample included two girls and two boys. The mean age at admission was 13.8years old [range 12-14]. The patients had on average 19 ECT sessions [range 16-26] and one patient received maintenance ECT. There was no effect of time before and after ECT start. ECT was associated with a significant decrease in SIB/AGG scores (p<0.001): mean aggression score post-ECT was half the pre-ECT value. ECT appears beneficial in severe, treatment-resistant SHBA in adolescents with intellectual disability.

P02-539 - Electroconvulsive Therapy in Treatment-Resistant Schizophrenia: a Case Report

Electroconvulsive therapy (ECT) is born as we know it in the first half of the twentieth century. Although initially introduced as a treatment for schizophrenia, soon proved more effective in affective disorders.Currently this therapy is second choice in the treatment of schizophrenia, representing only 10–20% of ECT treatments.We present a 55 years-old-woman diagnosed with Paranoid Schizophrenia in the adolescence, with several hospital admissions who was sent from sub-acute unit to receive ECT, given the null response to several pharmacological trials. The last, 1,200 mg amisulpride, 650 mg clozapine and 1,000 mg valproate per day, and Zuclopenthixol ampoule every 14 days. She verbalizes poorly structured persecutory, megalomaniac and nihilist delusional ideas, as well as auditory hallucinations which she does not clarify, and thought broadcasting phenomena. After withdrawing this medication and starting treatment with 30 mg haloperidol and 550 mg quetiapine, 14 bifrontotemporal ECT sessions were given.Given the disappearance of persecutory delusional ideas, and the decrease of auditory hallucinations, which she criticizes, the patient was discharged. After 4 months, she is still psychopathologically stable, and receiving maintenance ECT biweekly.ECT, either alone or in combination with conventional antipsychotic drugs, has been shown effective in a certain percentage of patients with acute schizophrenia, particularly in the catatonic subtype and also in schizoaffective disorder. The use and efficacy of ECT in chronic schizophrenia is a more controversial topic.Research should also focus on the determination of optimal number of ECT, the predictors of response and the efficacy of continuation and maintenance ECT.

Electroconvulsive Therapy in a Patient With Multiple Sclerosis and Recurrent Catatonia

Catatonia is a rare complication of multiple sclerosis (MS). We present a case of a 28-year-old inpatient with MS successfully treated with electroconvulsive therapy (ECT) after developing a catatonic syndrome. A subsequent relapse also responded to ECT, after which the patient received maintenance ECT for 13 months without complications. Follow-up 18 months later did not reveal any evidence of neurological deterioration. We conclude that ECT was a safe and effective treatment in this MS patient.

Cognitive functions after only one ECT session: A controlled study

The aim of the study was to determine the effects of one electroconvulsive therapy (ECT) session on learning, attention, and frontal and visuospatial functions. Twenty-four psychiatric patients receiving maintenance ECT participated in the study. The 12 patients in the experimental group were assessed before and 90 min after the ECT session. The twelve patients in the control group were assessed on arrival at the hospital and 90 min afterwards. They were then given their ECT session. The experimental group did not show significant learning, attention or frontal decline in the second assessment after the ECT session, in comparison with the control group. However, visuospatial ability was lower in experimental patients’ second assessment than it was in the control group's second assessment. This preliminary study showed that there was no significant clinical cognitive decline in psychiatric patients 90 min after a single ECT session. However, patients presented visuospatial dysfunction, suggesting that ECT sessions may cause some acute, mild dysfunction of right hemispheric cognitive functions.

Long-term maintenance ECT: a retrospective review of efficacy and cognitive outcome.

Continuation and maintenance electroconvulsive therapy (ECT) are used to prevent relapse of depression after a successful course of index ECT. Such a course of treatment is typically extended for as long as a year. However, some patients seem to require longer courses of maintenance ECT. Little is known about the outcomes of long-term use (> 1 year) of maintenance ECT. We reviewed our maintenance ECT practice for the year 2000 and found that 43 patients had been receiving maintenance ECT for more than a year. This retrospective study reviews the outcomes of these patients. All patients had depression associated with either unipolar or bipolar disorder or schizoaffective disorder. These patients had multiple medication or psychotherapy trials or both and multiple hospitalizations before receiving maintenance ECT. Effects on depressive symptoms, level of functioning, health care use, frequency of hospitalizations, and cognition are discussed. We conclude that extended maintenance ECT is efficacious and well tolerated and reduces hospital use for a population of chronically depressed patients refractory to medication.

Continuation ECT in Treatment-Resistant Schizophrenia

In patients with treatment-resistant schizophrenia (TRS), this study compared the efficacy of continuation treatment with flupenthixol alone, continuation electroconvulsive therapy (ECT) alone, and combined continuation ECT and flupenthixol. One hundred fourteen TRS patients received acute treatment (Phase I) with bilateral ECT and flupenthixol (12-24 mg/day). Fifty-eight patients met remitter criteria, including clinical stability during a 3-week stabilization period, and were eligible for the continuation treatment study (Phase II). Fifty-one patients enrolled in the single-blind Phase II continuation trial, and were randomized to the three treatment groups. The duration of the Phase II study was 6 months. Assessments of outcome included the Brief Psychiatric Rating Scale, Global Assessment of Functioning, and the Mini-Mental State Examination. Forty-five patients either relapsed or completed the Phase II study, and six patients dropped out. Among completers, 6 of 15 (40%) patients relapsed in the combined continuation ECT and flupenthixol group. In both the group treated with continuation ECT alone and that with flupenthixol alone, 14 of 15 (93%) patients relapsed. Analyses of intent-to-treat and completer samples demonstrated a marked advantage for the combination treatment condition in relapse prevention. Furthermore, all eight patients who received maintenance ECT combined with neuroleptic medication (Phase III study) maintained therapeutic benefits during the follow-up period of 3-17 months after the continuation treatment study. Among TRS patients who respond to acute combination treatment with ECT and neuroleptic therapy, continuation of this combination treatment is more effective in relapse prevention than use of ECT or neuroleptic therapy alone.