Experts Recommend Lithium and Antidepressants to Prevent ECT Relapse

The Challenge of Sustaining Remission After Electroconvulsive Therapy

Electroconvulsive therapy (ECT) remains one of the most effective acute interventions for severe major depressive disorder, achieving remission rates exceeding 50% and response rates near 75% [1]. However, sustaining this clinical response is a persistent challenge, with approximately half of all patients experiencing a depressive relapse within one year of a successful acute course [2]. While maintenance strategies such as continuation ECT and pharmacotherapy with lithium have demonstrated efficacy in reducing relapse risk [2, 3], the existing evidence base is limited by small sample sizes and heterogeneous study designs. Consequently, practicing psychiatrists lack standardized, operationalized guidelines to navigate long-term maintenance therapy and must often rely on individualized clinical judgment. A newly published global expert consensus aims to fill this gap by providing structured recommendations for post-ECT relapse prevention.

Structuring the Delphi Consensus Panel

While electroconvulsive therapy is a highly effective treatment for depression, clinicians face a significant challenge in maintaining patient remission. Relapse rates up to 50% within a year are reported after successful electroconvulsive therapy, underscoring the critical need for robust maintenance protocols. Previous studies have examined pharmacological and nonpharmacological relapse prevention strategies to sustain clinical benefits. However, while current guidelines provide general recommendations, no consensus-based or operationalized guidance exists regarding optimal relapse prevention for major depressive disorder. This leaves practicing psychiatrists without a standardized framework to manage high-risk patients once the acute treatment phase concludes. To address this clinical gap, researchers designed a study to identify commonly implemented relapse prevention strategies, evaluate their perceived effectiveness, and establish personalized clinical recommendations. The investigators conducted a multiround Delphi study (a structured, iterative survey technique used to gather expert opinions and achieve convergence on specific clinical practices). The panel included 18 global electroconvulsive therapy experts who evaluated various post-treatment protocols. To ensure rigorous agreement, consensus was defined as 80% or greater agreement on Likert-scale responses (standardized questionnaires where experts specify their level of agreement). Ultimately, the findings provide expert-based guidance on relapse prevention, offering physicians a practical tool to tailor maintenance therapy and keep patients in remission.

The Baseline Pharmacological Protocol

To establish a standardized baseline for post-treatment care, the expert panel reached a definitive agreement on a core medication regimen. Pharmacotherapy with lithium and an antidepressant was endorsed as an essential relapse prevention strategy for all patients. This foundational recommendation provides practicing psychiatrists with a clear, operationalized starting point for maintenance therapy, emphasizing the necessity of a robust pharmacological combination to sustain the clinical benefits achieved during the acute phase of electroconvulsive therapy. Regarding the specific components of this combination therapy, the experts outlined clear pharmacological choices. The endorsed antidepressant options included a tricyclic antidepressant, venlafaxine, or a prior effective antidepressant. For the practicing clinician, this guidance allows the maintenance protocol to be personalized based on a patient's individual treatment history and tolerability profile, while prioritizing agents that have demonstrated efficacy in managing severe major depressive disorder.

Risk Stratification and Continuation ECT

While the panel established that pharmacotherapy and continuation electroconvulsive therapy are core strategies, personalized adjustments based on clinical risk factors remain essential to optimize long-term patient outcomes. To guide these individualized treatment plans, consensus was reached on key clinical factors influencing relapse prevention, including treatment resistance, psychiatric comorbidities, and prior electroconvulsive therapy response. Physicians must evaluate these specific variables when designing a maintenance protocol, as a patient's historical response to treatment and the presence of concurrent psychiatric conditions directly dictate the necessary intensity of post-treatment care. For individuals identified as highly vulnerable to symptom recurrence, the panel provided specific guidance on extending somatic therapy. Continuation electroconvulsive therapy by means of tapering, rather than abrupt cessation, was recommended for patients at high risk of relapse and those with severe or psychotic depression. This structured step-down process helps stabilize the clinical response achieved during the acute phase and prevents the rapid deterioration often observed when treatment is suddenly withdrawn. Beyond somatic and pharmacological interventions, the experts clarified the role of psychological support during the maintenance phase. Psychotherapy was considered beneficial as an adjunctive rather than a standalone treatment. Clinicians are advised to integrate psychotherapeutic modalities to support medication adherence and address psychosocial stressors, but they should not rely on psychological interventions alone to prevent depressive relapse following a successful acute treatment course.

Unresolved Questions in Maintenance Therapy

Despite reaching an agreement on foundational pharmacological and electroconvulsive therapy maintenance protocols, the expert panel could not achieve the required 80 percent agreement threshold on several alternative interventions. Specifically, no consensus was reached on the role of repetitive transcranial magnetic stimulation as a strategy to sustain remission. Similarly, the experts concluded that no consensus was reached on the role of esketamine in the post-treatment phase. For practicing psychiatrists, this indicates that while these therapies are increasingly utilized in treatment-resistant depression, their specific utility for relapse prevention immediately following successful electroconvulsive therapy remains undefined by current expert guidelines. The panel also encountered limitations regarding the timeline of maintenance care. No consensus was reached on the optimal treatment duration of relapse prevention beyond 6 months. Consequently, clinicians must rely on individualized patient assessments and ongoing clinical monitoring to determine when or if to taper maintenance therapies after the initial half-year period. Because critical gaps remain in the evidence base, the researchers emphasize that further empirical research is needed to refine guidelines and improve long-term outcomes. Future clinical trials focusing on extended treatment durations and the integration of newer modalities will be necessary to provide physicians with comprehensive, evidence-based protocols for managing major depressive disorder after acute electroconvulsive therapy.

References

1. Bahji A, Hawken ER, Sepehry AA, Cabrera CA, Vazquez G. ECT beyond unipolar major depression: systematic review and meta-analysis of electroconvulsive therapy in bipolar depression.. Acta psychiatrica Scandinavica. 2019. doi:10.1111/acps.12994

2. Rovers JJE, Zeijl NTV, Tendolkar I, Dols A, Eijndhoven PFPV. Systematic review on relapse-prevention strategies following successful electroconvulsive therapy for major depressive disorder.. BJPsych open. 2026. doi:10.1192/bjo.2025.10946

3. Jelovac A, Braithwaite R, Kellner CH, McLoughlin DM. Continuation electroconvulsive therapy combined with pharmacotherapy for depression relapse prevention: A systematic review and meta-analysis.. Psychological medicine. 2025. doi:10.1017/S0033291725101608