Am J Psychiatry 156:12, December 1999 1865Regular ArticlesAcute Efficacy of ECT in the Treatmentof Major Depression in the Old-OldJames D. Tew, Jr., B.A., Benoit H. Mulsant, M.D., Roger F. Haskett, M.D., Joan Prudic, M.D., Michael E. Thase, M.D., Raymond R. Crowe, M.D., Diane Dolata, M.S.W., Amy E. Begley, M.A., Charles F. Reynolds III, M.D., and Harold A. Sackeim, Ph.D.Objective: There are few data addressing the outcome of ECT for persons over 75 yearsof age. In a prospective, multisite study, the authors compared characteristics and treatmentoutcomes of adult (59 and younger), young-old (60 to 74 years), and old-old (75 and older)patients treated with ECT for major depression. Method: At four hospitals, 268 patients withprimary unipolar major depression and scores of at least 20 on the 24-item Hamilton Depres-sion Rating Scale were treated with suprathreshold right unilateral or bilateral ECT in a stan-dardized manner. Demographic variables, clinical characteristics, and short-term outcomesof the three groups were compared. Results: The demographic and clinical characteristicsof the old-old patients were similar to those of the young-old patients, whereas both groupsdiffered from the adult patients on these variables. Both older groups had significantly greaterburdens from physical illness and global cognitive impairment at baseline than the adult sub-jects. Both older groups had shorter index depressive episodes and were less likely to havehad inadequate responses to adequate medication trials before ECT. The older groups hadhigher seizure thresholds, but the three groups received similar courses of treatment. Theadult patients experienced a significantly lower rate of ECT response (54%) than the young-old patients (73%), while the old-old patients had an intermediate rate of response (67%).Conclusions: Despite a higher level of physical illness and cognitive impairment, even theoldest patients with severe major depression tolerate ECT in a manner similar to that foryounger patients and demonstrate similar or better acute response. (Am J Psychiatry 1999; 156:18651870)Because of comorbid medical conditions, poor toler-ance of psychotropic medications, and psychotic fea-tures or marked disability associated with depression,ECT is often the treatment of choice in older patientswith severe depression (1). As a result, the elderly con-stitute more than one-half of American patients whoreceive ECT for the treatment of depression (2). Sev-eral studies have addressed the risks and benefits ofECT for older patients (1). However, there is a paucityof data specifically addressing the outcome of ECT forpersons over 75 years of age, often referred to as theold-old (35). Data relevant to these patients areusually combined with data on patients who may be10 or 20 years younger, even though there is great vari-ability in physiological, clinical, economic, and socialPresentedinpartatthe11thannualmeetingoftheAmericanAssociationforGeriatricPsychiatry,SanDiego,March811,1998.ReceivedOct.20,1998;revisionreceivedMay24,1999;acceptedMay28,1999.FromtheWesternPsychiatricInstituteand Clinic, Department of Psychiatry, University of Pittsburgh; theDepartmentofBiologicalPsychiatry,NewYorkStatePsychiatricInstitute, New York; the Departments of Psychiatry and Radiology,CollegeofPhysiciansandSurgeons,ColumbiaUniversity,NewYork; and the Department of Psychiatry, University of Iowa SchoolofMedicine,IowaCity.AddressreprintrequeststoDr.Mulsant,Western Psychiatric Institute and Clinic (E1226), 3811 OHara St.,Pittsburgh, PA, 15213; mulsantbh@msx.upmc.edu (e-mail).SupportedinpartbyNIMHgrantsMH-30915,MH-35636,MH-48512,MH-52247,MH-57009,MH-01613,MH-00295,andMH-19986. MECTA Corporation donated equipment to the investigators.TheauthorsthankTracyFlynn,M.A.,andKerithSpignall,B.A.,for assistance with data collection.1866 Am J Psychiatry 156:12, December 1999ECT FOR THE OLD-OLDcharacteristics among persons 65 and over (3, 4). Forinstance, suicide risk doubles between ages 65 and 85(6, p. 105).To our knowledge, five studies have examined theoutcome of ECT in the old-old (711). In each studyECT was found to be safe and effective. The design offour of these studies was limited by the use of retro-spective chart review (7, 911), lack of a comparisongroup (7, 911), or small study group size (9). Theonly prospective study of which we are aware used astandardized rating scale to examine clinical outcomeamong78patientsofvaryingages(8).Thisstudyshowed a trend toward greater improvement in the 20old-old patients than in younger patients.In the context of a large prospective, multisite studywith standardized ECT administration and clinical as-sessment, we compared the outcome of ECT in adult(59 years of age and younger), young-old (60 to 74years), and old-old (75 years and older) patients withmajor depression. We hypothesized that the old-oldpatients receiving ECT would have a higher burden ofphysicalillness,wouldrespondaswellasyoungeradultsandyoung-oldpatients,butwouldbemorelikely to experience cognitive impairment.METHODThe subjects participated between June 1992 and March 1998 ina multisite study that prospectively examined the relationship ofmedication resistance to ECT response and subsequent relapse. Wehave previously reported detailed study methods and preliminary re-sults on a subgroup of subjects (12, 13). Patients referred for ECT atfour hospitals (Carrier Foundation, Belle Mead, N.J.; New YorkState Psychiatric Institute, New York; University of Iowa Hospitalsand Clinics, Iowa City; and the Western Psychiatric Institute andClinic, University of Pittsburgh Medical Center) were invited to par-ticipate if they met the Research Diagnostic Criteria (RDC) (14) foran episode of primary, unipolar major depression and if they had ascore of at least 20 on the 24-item Hamilton Depression Rating Scale(15). Written informed consent was obtained from all study patientsafter the procedures had been fully explained.The patients were interviewed before ECT with the Schedule forAffective Disorders and Schizophrenia (16). Diagnoses were thenmade according to both the RDC and DSM-III-R. If psychotic fea-tures were present at any time during the index episode, the episodewas classified as psychotic. In almost all cases the RDC and DSM di-agnoses were identical, and DSM diagnoses are presented here. Pa-tients were excluded if they had a history of schizophrenia, schizoaf-fectivedisorder,orotherfunctionalpsychosis,hadahistoryofneurological injury or disorder (including a dementing disorder),had abused substances other than nicotine within the past year, orhad received a course of ECT within the past 6 months.Before treatment, the physical status of each patient was assessedwith a modified version of the Cumulative Illness Rating ScaleGe-riatrics (17, 18). Medical burden was rated for each of 14 organ sys-tems on a 5-point scale (0=no problem, 1=mild, 2=moderate, 3=se-vere, 4=extremely severe).Before starting and within 3 days of completing ECT, patientswere rated with the 24-item version of the Hamilton depressionscale, the Global Assessment Scale (GAS) (19), and the Mini-MentalState (20). To ensure adequate interrater reliability, the raters partic-ipated in annual training sessions and research interviews were vid-eotaped and independently re-rated by an off-site rater. Intraclasscorrelation coefficients for the site and off-site ratings exceeded 0.90for the Hamilton depression scale and GAS. Resistance to antide-pressant treatment before ECT was classified by using the Antide-pressant Treatment History Form (12, 13), with the duration, oraldose, blood levels, compliance, and clinical outcome for each medi-cation trial received during the index episode taken into account.All psychotropic medications (with the exception of lorazepam,up to 3 mg/day) were tapered before ECT was started. The patientsreceived either right unilateral ECT with the dElia placement or bi-lateral ECT with the bifrontotemporal placement. At all sites thesame titration schedulea methods of limits procedurewasused to empirically quantify seizure threshold at the first treatmentwith either right unilateral or bilateral ECT (21, 22). For a smallnumber of patients treated at one site (N=36), initial electrode place-ment and stimulus intensity were selected randomly. For all patientstreated at the three other sites (N=232), initial electrode placementwas decided according to the following guidelines: treatment startedwith suprathreshold right unilateral ECT unless the patient had notresponded to suprathreshold right unilateral ECT in the past or thepatients depression was so severe that the patients psychiatrist re-quested bilateral ECT. For right unilateral treatment, stimulus inten-sity was increased to a minimum of 150% above the empirically de-termined right unilateral seizure threshold (i.e., 2.5 times seizurethreshold). At all sites, electrode placement was switched to bilateralECT if the patient did not show significant improvement after atleast five suprathreshold right unilateral treatments. For bilateralECT, stimulus intensity was set 150% above the empirically deter-mined bilateral seizure threshold (i.e., 2.5 times seizure threshold).There was no preset maximum number of treatments for eithermodality. All patients were encouraged to continue ECT until theyhad fully responded (i.e., they had experienced complete or almostcomplete resolution of their depressive symptoms) or until they hadbeen treated with at least 812 bilateral treatments and they hadshowed no further improvement during the past 23 bilateral treat-ments. Some patients (or their attending psychiatrists) refused toswitch from right unilateral to bilateral ECT and/or decided to dis-continueECTbeforetheyreceivedtherecommendedcompletecourse.At all sites, ECT was administered by using a custom-modifiedbrief-pulse, constant-current MECTA SR1 device (Lake Oswego,Ore.). The four devices were calibrated and modified similarly to de-liver a maximal energy of up to 200 J at an impedance of 200 (or1250 mC). Thirteen (4.6%) of the patients in this study had rightunilateral seizure thresholds higher than 240 mC and would nothave been able to receive a stimulus intensity equal to 2.5 times theright unilateral seizure threshold if they had been treated with one ofthe commercial devices currently available in the United States. Forvirtually all patients, the medications given at the time of ECT in-cluded atropine (0.4 mg i.v.), methohexital (0.751.0 mg/kg), andsuccinylcholine (0.751.0 mg/kg).The patients were divided into three groups on the basis of age: 59years and younger, 60 to 74 years, and 75 years and older. The de-mographic, clinical, and treatment characteristics of these threegroups were compared with chi-square analyses and analyses ofvariance (ANOVAs), as indicated; when statistical differences werefound, the Tukey post hoc test was used for pairwise comparisons.Patients with Hamilton depression scores of 10 or less after comple-tion of ECT were classified as responders, and the response rates ofthe three groups were compared by using chi-square analyses.To further explore whether there was an interaction betweenstudy site, age, physical burden, and pre-ECT Hamilton depressionscore in predicting response, we also performed a logistic regressionusing these variables as predictors and response as the dependentvariable(withpartialrespondersincludedinthenonrespondergroup).A small number of patients did not have post-ECT scores, eitherbecause they discontinued ECT before they received at least fivetreatments or because their diagnoses were changed once more in-formation became available. There was no statistical difference inthe proportions of these dropouts across the three age groups:15.0% of the patients 59 years and younger (20 of 133), 12.7% ofthose 60 to 74 years old (eight of 63), and 8.3% of those 75 yearsand older (six of 72) (2=1.90, df=2, p=0.39).Am J Psychiatry 156:12, December 1999 1867TEW, MULSANT, HASKETT, ET AL.RESULTSDemographicandclinicalcharacteristicsofthethree study groups are contrasted in table 1. Whencompared to both groups of older patients, the pa-tients aged 59 years and younger had a significantlylower medical burden (total score on Cumulative Ill-ness Rating ScaleGeriatrics and number of systemsrated as having a severe or extremely severe problem),lower age at onset of major depression, smaller pro-portionofpatientswithmelancholia,andhighermeanbaselineMini-MentalStatescore.Theyalsowere less likely to have received ECT in the past, hadlonger current episodes, and were more likely to bemedication resistant. The patients aged 60 to 74 yearshad a significantly lower medical burden than thoseaged 75 years and older. Otherwise, the two older agegroups did not differ.Table 2 presents the treatment characteristics of thethree study groups as a function of treatment type: uni-lateral ECT only, bilateral ECT only, or both unilateraland bilateral ECT (patients who were randomly as-signed to initial treatment with right unilateral or bilat-eral ECT were excluded). With right unilateral ECT,the patients aged 59 years and younger had a signifi-cantly lower seizure threshold than each of the oldergroups. There were no significant differences amongthe age groups in total number of treatments or likeli-hood of switching from unilateral to bilateral ECT.The therapeutic and global cognitive outcomes forthe three groups are summarized in table 3. Patientsaged 59 years and younger had higher pre- and post-ECT Hamilton depression scale scores and a lower rateof response than patients aged 60 to 74 years. Simi-larly, they experienced a smaller improvement as mea-sured by the GAS. A logistic regression failed to reveala significant association between response and physi-cal burden (score on the Cumulative Illness RatingScaleGeriatrics) after age, study site, and pre-ECTHamilton depression score were controlled for (2=0.15, df=1, p=0.70). In the three age groups, therewere small decreases in Mini-Mental State mean scoresafter ECT (table 3); this decrease reached statisticalsignificance only for the youngest patients (t=3.4, df=84, p=0.001; young-old: t=0.9, df=33, p=0.40; old-old:t=1.1, df=27, p=0.28).DISCUSSIONTo our knowledge, this report includes the largestnumber of patients aged 75 and over enrolled in a pro-spective study of ECT using standardized rating scales.Several findings deserve comment.TABLE 1. Demographic and Clinical Characteristics of Adult, Young-Old, and Old-Old Depressed Patients Treated With ECTCharacteristicTotalNAdults (