Journal of Psychiatric Research 105 (2018) 132–136

Contents lists available at ScienceDirect

Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/jpsychires

Clinical outcome of maintenance electroconvulsive therapy in comorbid T

Posttraumatic Stress Disorder and major depressive disorder
Naser Ahmadia,∗, Lori Mossb, Peter Hausera, Charles Nemeroffc, Nutan Atre-Vaidyab
a
David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
b
Captain James A Lovell Federal Healthcare Center, Chicago Medical School, North Chicago, IL, United States
c
Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) are prevalent and
Major depressive disorder frequently comorbid. Approximately 42–48% of patients with PTSD also meet diagnostic criteria for MDD.
Posttraumatic stress disorder Maintenance electroconvulsive therapy (mECT) has been found to be efficacious for the prevention of recurrence
Electroconvulsive therapy of MDD. This study investigated the efficacy of mECT in the treatment of MDD with and without comorbid
Heart rate variability
syndromal PTSD.
Clinical global impression severity scale
Suicide
Methods: This retrospective study includes 36 patients, 26 with MDD and 10 with comorbid MDD & PTSD
receiving monthly mECT for a mean of 1.5 years. The mean age was 52 ± 14 years and 25% were female. The
change in PTSD and MDD symptoms in response to mECT was assessed using Clinical Global Impression -
Severity Scale (CGI-S). Heart rate variability (HRV), 12-month hospitalization rate, suicide rate and all-cause
mortality in response to mECT were assessed and compared between groups using repeated generalized linear
regression (GLM) analysis.
Results: At mECT baseline, there were no statistically significant differences in CGI-S scores, HRV between pa-
tients with MDD alone and those with comorbid MDD and PTSD (P > 0.05). After 12-months of mECT, a
significant increase in HRV (mean difference: 10.9 95%CI 4.8–20.3, p = 0.001) and decrease in CGI-S overall
(mean difference: 3.5, 95% CI 3.3–3.6, p = 0.001)], PTSD (mean difference: 3.4, 95% CI 3.2–3.6, p = 0.001)],
and MDD (mean difference: 3.8, 95% CI 3.5–3.9, p = 0.001)] symptoms in both groups were noted (p < 0.05).
No psychiatric hospitalization or suicide occurred in any of the patients.
Conclusions: Maintenance ECT is associated with improved HRV, reduction of both major depression and PTSD
symptoms, and a favorable clinical outcome.

1. Introduction PTSD compared to antidepressant therapy alone (Ahmadi et al., 2016).

The prevalence of combat posttraumatic Stress Disorder (PTSD) in
United States is 5–20% and is even greater in military personnel serving
in Iraq and Afghanistan. Syndromal PTSD and major depressive dis-
order (MDD) are frequently comorbid, as our previous report in which
42–48% of patients with PTSD meet DSM criteria for MDD (Ahmadi
et al., 2016).
Prior studies showed that electroconvulsive therapy (ECT) (Yrondi
et al., 2018) is more effective than antidepressants in reducing de-
pression and suicidal intent among patients with severe depression
(Group, 2003). We recently reported the efficacy of an acute course of
ECT in patients with comorbid PTSD and MDD (Ahmadi et al., 2016).
An acute course of ECT produced a significant reduction in symptoms of
Furthermore, ECT treatment were independently associated with a re-
duced risk of mortality in PTSD patients, most robust in reduction of
cardiovascular mortality (Ahmadi et al., 2016).
Previous studies showed that decreased heart rate variability (HRV),
an early reversible stage of alterations in autonomic nervous system
activity between sympathetic and parasympathetic input, is associated
with the severity of PTSD and MDD symptoms. Furthermore, improved
HRV in response to the acute course of ECT was associated with fa-
vorable clinical outcomes (Ebert et al., 2010; Kemp et al., 2012).
The American Psychiatric Association (APA) task force on ECT
states that maintenance ECT (mECT), carried out more than 6 months
after an index course should be available to patients who have re-
sponded well to ECT treatment and when the treatment is preferred by

∗
Corresponding author. David Geffen School of Medicine, University of California Los Angeles, Olive View UCLA Medical Center, 1445 Olive View Dr, Sylmar, CA,
91342, United States.
E-mail address: ahmadi@ucla.edu (N. Ahmadi).

https://doi.org/10.1016/j.jpsychires.2018.08.023
Received 26 April 2018; Received in revised form 11 July 2018; Accepted 30 August 2018
0022-3956/ © 2018 Elsevier Ltd. All rights reserved.
N. Ahmadi et al.
the patient (APA Task Force, 2001). Recurrence of MDD symptoms
occur in more than 50% of MDD patients, who responded to an index
course of ECT treatment over the ensuing 6–12 months in spite of re-
ceiving appropriate psychotropic medications (Bourgon and Kellner,
2000). Numerous studies suggest that maintenance ECT (mECT) pre-
vents recurrence of MDD after acute ECT, improve patients’ response to
psychotropic medications, and reduce health care costs (Martinez-
Amoros et al., 2012). Although PTSD is frequently comorbid with other
psychiatric disorders and a predicator of poor outcome of the comorbid
disorders (Boscarino, 2006; Dedert et al., 2010), the effect of mECT on
patients with comorbid PTSD and MDD has not been extensively stu-
died.
The Veteran Health Administration (VHA) is the largest health care
system in the nation and provides integrated comprehensive assessment
of psychiatric and other medical disorders among all veterans in the
primary care setting (Baker et al., 2008). We hypothesized that mECT
would improve core PTSD and MDD symptoms as well as heart rate
variability and is associated with favorable clinical outcome. This study
investigated the efficacy of mECT in MDD patients with and without
PTSD using VHA electronic medical records.
2. Methods
This retrospective cohort study is inclusive of 36 consecutive mECT
patients [10 with both MDD and PTSD, and 26 with MDD alone] in the
Captain James Lovell Federal Health Care Center (FHCC) in North
Chicago, IL. mECT was recommended to all patients who responded to
an acute course of ECT (90% of patients received ECT), associated with
high patients’ acceptance rate (65%), as well as high retention rate
(92%) to receive and continue mECT > 12-month, respectively.
All consecutive patients with MDD, with and without comorbid
PTSD, who were free of other major psychiatric disorders without
known CAD and vasoactive drugs who underwent bifrontal mECT at
FHCC during 2012–2014 after completion of their acute course of ECT
were included.
Demographic characteristics, clinical data, and outcome of studied
patients were obtained using VHA administrative, research and clinical
electronic medical records. Based on APA guidelines (APA Task Force,
2001), mECT was recommended as one of the first-line treatment op-
tions for MDD at FHCC, and upon obtaining informed consent, eligible
patients received mECT. All patients were evaluated for a mean follow
up period of 18 months [interval 12–36 mo].
2.1. Definition of MDD and PTSD
PTSD and MDD were diagnosed using the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition.
2.2. ECT procedure
All studied patients received monthly mECT using a Thymatron IV
ECT device (Somatics LLC, Lake Bluff, Illinois, USA). All patients re-
ceived bifrontal (BF) mECT, with stimulus dose administration at least
200% above the seizure threshold based on the age-based method, with
an average of 14 ± 1 ECT sessions. Procedures for anesthesia and
determination of seizure adequacy (electroencephalogram (EEG)
≥25sec) followed standardized clinical protocols compatible with
current standards of care. Anesthesia management consisted of pre-
treatment with glycopyrrolate, followed by induction with an anes-
thetic agent (methohexital, 0.75 mg/kg or propofol 1 mg/kg in 5 cases),
followed by succinylcholine (0.75 mg/kg) for muscle relaxation.
Patients received oxygen with 100% O2 with positive pressure
throughout the procedure, using a disposable bag and mask. Blood
pressure, heart rate, and pulse oximetry were monitored before, during,
and after mECT. Electroencephalogram (EEG) was recorded from a two-
channel device using right and left frontomastoid placements and
133
Journal of Psychiatric Research 105 (2018) 132–136
quantitative EEG indices of mECT were measured. Motor duration of
seizures was recorded using a two-lead EMG from the right foot.
2.3. Clinical Global Impression – severity of illness scale (CGI-S)
The CGI-S is rated on a 7-point scale measuring the severity of
symptoms at baseline and 12-month of mECT. The range of responses
are from 0 = Not assessed, 1 = Normal, 2 = Borderline ill, 3 = Mildly
ill, 4 = Moderately ill, 5 = Markedly ill, 6 = Severely ill, to 7 = Among
the most extremely ill patients. The CGI-S of overall symptoms, PTSD
symptoms, and MDD symptoms in patients at baseline, after the acute
course of ECT and after mECT were measured.
2.4. Heart rate variability (HRV)
The time-domain method was used to measure HRV. The standard
deviation of the average NN interval (SDANN) of the 5-min mean RR
intervals was calculated at baseline and 12-month mECT. CGI-S and
HRV were captured from electronic medical records by trained physi-
cians with inter-rater reliability of 98%.
2.5. Clinical outcomes
The end primary points were psychiatric hospitalization, all-cause
mortality, and suicide verified by the Social Security Death Index ob-
tained from electronic medical records including VA Beneficiary
Identification and Records Locator system (BIRLS), VA Centers for
Medicare & Medicaid Services (CMS) vital status, Social Security
Administration death index (SSA), and National Death Index Data.
Suicide and all-cause mortality was ascertained in all patients.
3. Statistical analysis
Characteristics of the studied patients summarized as Mean ± SD
and proportions. Continuous variables were compared by analysis of
variance (ANOVA) and categorical variables were compared by
Cochran–Mantel–Haenszel statistics. Generalized linear model regres-
sion analyses were used to assess the change in CGI-S and HRV in PTSD
and MDD symptoms in response to mECT. Multivariable mixed re-
gression analyses were employed to assess the relation on improved
HRV (above median of 85 ms) with change in CGI-S. All statistical
analyses were performed with SPSS version 24 (SPSS Inc., Chicago, IL,
www.spss.com) and STATA version 14.0 (www.stata.com, StataCorp,
College Station, TX). The level of significance was set at P < 0.05 (2-
tailed). This study was approved and overseen by the Institutional
Review Board Committee of the Hines VA Health Care System, Chicago,
IL.
4. Results
There was no recurrence of PTSD and MDD symptoms between the
end of the acute course of ECT and the start of mECT (p > 0.05).
Baseline mECT CGI-S PTSD and MDD symptoms were significantly
lower compared to corresponding values before acute course of ECT
(p < 0.001).
At mECT baseline, there were no significant differences in age, sex,
body mass index, prevalence of diabetes mellitus, coronary artery dis-
ease, family history of psychiatric disorder, history of psychiatry hos-
pitalization, duration of MDD as well as antidepressant therapy in the
MDD patients with and without PTSD (p > 0.05). The mECT baseline
CGI-S of overall symptoms and HRV, prior to mECT, were not sig-
nificantly different between the MDD group with and without PTSD
(Table 1) (p > 0.05). At 12-month mECT, no recurrent episode of
MDD, PTSD, psychiatry hospitalization or suicide occurred in either of
the treatment groups. There was no statistically significant difference in
mortality rate in patients with MDD alone (n = 0), compared to
N. Ahmadi et al. Journal of Psychiatric Research 105 (2018) 132–136

Table 1 5. Discussion
The Baseline and 12-months clinical characteristics of MDD patients with and
without PTSD receiving mECT. The present study demonstrates several novel findings: (1) mECT is
Variable MDD without PTSD MDD with PTSD P value associated with a significant reduction of symptoms of PTSD and MDD,
N = 26 N = 10 as well as an increase in HRV; (2) the suicide, mortality and psychiatry
hospitalization rate of patients with comorbid PTSD and MDD treated
Baseline
with mECT is not statistically different from those with MDD only; (3)
Age (years) 52 ± 14 51 ± 14 0.8
Gender (female) 27%(7) 20%(2) 0.4 increased HRV in response to mECT was associated with a significant
Antidepressant Therapy 88%(23) 90%(9) – reduction of both PTSD and MDD symptoms.
Psychiatric Hospitalization 2 (1–4) 2 (1–4) 1 mECT has been proven as safe and effective, even in elderly pa-
Diabetes Mellitus 31%(8) 30% (3) 0.9
tients, with no adverse cognitive effects after 1 year of treatment
Hypertension 69%(18) 70%(7) 0.9
Hyperlipidemia 61%(16) 60%(6) 0.9
(Brown et al., 2014; Navarro et al., 2008; Trevino et al., 2010). mECT
Body Mass Index 29.8 ± 3.5 29.7 ± 3.7 0.9 has been demonstrated to reduce the number of admissions and the
PTSD Duration – 54 ± 18 – mean duration of hospitalization in elderly patients with severe mental
MDD Duration 35 ± 12 33 ± 11 0.7 illness (Shelef et al., 2015).
Family History of MHD 31%(8) 30%(3) 0.9
Family History of CAD 19%(5) 20%(2) 0.9
CGI-S - Before Acute course of ECT 5.1. mECT, and clinical outcome in patients with PTSD and MDD
Overall Symptoms 5.8 ± 0.2 6.0 ± 0.3 0.8
MDD symptoms 5.8 ± 0.2 5.9 ± 0.3 0.9 The rate of suicide in major depression is between 5 and 15% in the
PTSD Symptoms – 6.1 ± 0.3 –
outpatient setting, and increased to 15–20% in the inpatient setting,
CGI-S - mECT baseline (After Acute course of ECT)
Overall Symptoms 3.8 ± 0.3 3.9 ± 0.2 0.8∗
especially in those with comorbid PTSD (Bostwick and Pankratz, 2000;
MDD symptoms 3.8 ± 0.3 3.7 ± 0.2 0.8∗ Rihmer et al., 2009). Prior studies indicated a significant lower recur-
PTSD Symptoms – 4.0 ± 0.2 – rence rate of severe mental disorders with mECT (11–33%) compared
HRV 81.1 ± 31.2 80.6 ± 32.1 0.9 to those with an index course of ECT or antidepressant therapy alone
Follow Up
(50–70%) (Martinez-Amoros et al., 2012; Navarro et al., 2008; Russell
Antidepressant Therapy 8%(2) 10%(1) 0.9
Antipsychotic Therapy 0 0 – et al., 2003). Gupta et al. compared clinical outcome of 19 patients with
Benzodiazepine Therapy 0 0 – MDD on mECT and 19 patients with MD on antidepressant therapy and
Anticonvulsant Therapy 0 0 – reported a reduced rate of psychiatry hospitalization and a decrease in
6-month Hospitalization 0 0 – length of hospital stay in the mECT group (Gupta et al., 2008). The
12-month Suicide 0 0 –
12-month Mortality 0 1 0.3
current study confirms and extends the findings of previous studies with
CGI-S significant reduction of core PTSD and MDD symptoms measured by
Overall Symptoms 2.1 ± 0.2 2.7 ± 0.2 0.1∗∗ CGI-S, no psychiatric hospitalization, suicide or psychiatry related
MDD symptoms 2.1 ± 0.2 2.3 ± 0.1 0.5∗∗ mortality in patients with PTSD and MDD who received mECT.
PTSD Symptoms – 2.7 ± 0.3 –∗∗
HRV 89.1 ± 35.2 87.8 ± 33.2 0.7∗∗
5.2. mECT, increase of HRV and reduction of MDD and PTSD symptoms
*p < 0.001 mECT baseline values compared to corresponding measures before
acute course of ECT. Prior studies showed that improved HRV were associated with re-
**p < 0.001 mECT follow-up values compared to corresponding measures at duction of inflammation, psychological distress, impaired hypotha-
mECT baseline. lamic-pituitary-adrenal axis (HPA) activity, autonomic nervous dys-
function, decrease of PTSD and MDD symptoms, and increase in
patients with comorbid MDD and PTSD (n = 1; due to cardiovascular positive connectedness as well as favorable clinical outcomes (Ahmadi
disease)(p = 0.3). A significant increase in HRV and decrease in CGI-S et al., 2016; Tateishi et al., 2007; Wang et al., 2016). Ebert et al. studied
from over clinical moderate symptom to subtle without functional im- the relationship of HRV and response to treatment in 24 patients re-
pairment in both group at 12-months mECT compared to mECT base- ceiving ECT and reported that a significant correlation between de-
line after acute course of ECT was noted (p < 0.05). [Table 1]. crease in MDD symptoms and improvement of HRV occurred during the
Repeated GLM analysis showed a significant reduction of CGI-S course of ECT (Ebert et al., 2010). The current findings reconfirm
overall symptoms at 6- and 12-month mECT with a mean difference of previous studies in addition to providing evidence of a significant as-
1.7 (95% CI 1.5–1.8, p-0.0001) and 3.5 (95% CI 3.3–3.6, p-0.0001), sociation between improved HRV and a decrease in both PTSD and
respectively, compared to mECT baseline CGI-S. Fig. 1 illustrates the MDD symptoms following mECT. These findings highlight the im-
significant decrease in both CGI-S PTSD and MDD symptoms in re- portant role of mECT in simultaneous reduction of PTSD and MDD
sponse to both acute and maintenance course of ECT which was more symptoms as well as improving HRV and favorable clinical outcomes.
robust after 12-months of mECT (P < 0.05). The data in Table 2 re- These salutary effects in response to mECT have been associated with
veals comparable changes in CGI-S overall-symptoms and HRV in re- normalization of HRV and improvement indices of HPA axis, in-
sponse to mECT in patients with MDD alone versus patients with co- flammation, and autonomic function (Ahmadi et al., 2016; Dennis
morbid MDD & PTSD (p > 0.05). et al., 2017; Servant et al., 2009).
Mixed regression analysis revealed a significant increase in HRV
with a mean difference of 10.9 (95% CI 4.8–20.3, p = 0.001) at 12- 5.3. Clinical implications
months of mECT, compared to mECT baseline. Table 3 shows that in-
creased HRV was associated with 11.8 times more reduction in CGI-S The current study demonstrates that mECT may reduce core
overall symptoms at 12-month mECT, compared to reduced HRV symptoms of PTSD independent of improvement in depression. This
(p < 0.05). Fig. 2 shows increased HRV is associated with a significant may be an efficacious treatment option for patients with severe, chronic
decrease in both CGI-S PTSD and MDD symptoms, which was more refractory PTSD.
robust in MDD only patients (p < 0.05).
5.4. Study limitation

This study has several limitations. This is a single center,

134
N. Ahmadi et al. Journal of Psychiatric Research 105 (2018) 132–136

Fig. 1. The Change in MDD and PTSD symptoms in response to mECT, compared to baseline (before and after acute course of ECT).

Table 2 Research/grants
Comparison on changes in overall symptoms and HRV in response to mECT
between patients with comorbid MDD and PTSD, compared to those with MDD National Institutes of Health (NIH), Stanley Medical Research
only. Institute.
Model MDD without MDD with PTSD
PTSD
Consulting (last three years)
Change in HRV* 1.0 (Ref) 0.09 (−0.8–0.3), p = 0.1
Change in CGI-S overall 1.0 (Ref) 1.2 (−1.9- 2.3), p = 0.5 Xhale, Takeda, Taisho Pharmaceutical Inc., Intra-cellular
symptoms* Therapeutics, Bracket (Clintara), Sunovion Pharmaceuticals Inc.,
Janssen Research & Development LLC, Magstim, Inc., Navitor
*Change from baseline to 12 months follow up.
GLM Analysis, adjusted for age, gender, hypertension, hyperlipidemia, diabetes, Pharmaceuticals, Inc.
duration of MDD and anti-depressant therapy.
Stockholder
Table 3
The relation of increased HRV with decrease in CGI-S overall symptoms in re- Xhale, Celgene, Seattle Genetics, Abbvie, OPKO Health, Inc.,
sponse to mECT. Bracket Intermediate Holding Corp., Network Life Sciences Inc.,
Model HR Below HR Above Median Antares, Gitead
Median

Decrease in CGI-S overall 1.0 (Ref) 11.8 (95% 8.8–14.8, Scientific advisory boards
symptoms p = 0.001)
American Foundation for Suicide Prevention (AFSP), Brain and
Increased HRV: HR above median: HRV≥85 ms.
Behavior Research Foundation (BBRF) (formerly named National Alliance
Mixed regression analysis, adjusted for age, gender, hypertension, hyperlipi-
demia, diabetes, duration of MDD and anti-depressant therapy.
for Research on Schizophrenia and Depression [NARSAD]), Xhale, Anxiety
Disorders Association of America (ADAA), Skyland Trail, Bracket
retrospective, non-randomized, observational study of MDD patients (Clintara), RiverMend Health LLC, Laureate Institute for Brain
with and without PTSD who received mECT. There was no placebo Research, Inc.
treatment group. We utilized a CGI-S for assessing the severity of illness
due to the availability of these measures for all study patients and lack Board of directors
of availability of other standardized scales for this population. Further
randomized controlled clinical efficacy trials are warranted to further AFSP, Gratitude America, ADAA.
evaluate the effects of mECT treatment on PTSD with and without co- Income sources or equity of $10,000 or more:
morbid PTSD. American Psychiatric Publishing, Bracket (Clintara), CME
Outfitters.

6. Conclusion
Patents
This study shows the efficacy of mECT in patients with comorbid
Method and devices for transdermal delivery of lithium (US
PTSD and MDD. mECT is independently associated with improved HRV,
6,375,990B1) Method of assessing antidepressant drug therapy via
reduction in symptoms of both MDD and PTSD, and is associated with a
transport inhibition of monoamine neurotransmitters by ex vivo assay
favorable clinical outcome.
(US 7,148,027B2).

Conflicts of interest/disclosures Speakers bureau

Dr. Nemeroff has disclosures as following: None.

135
N. Ahmadi et al.
Fig. 2. Improved HRV is associated with more robust decrease in overall symptoms, especially in those with MDD only.
Funding
The other co-authors have no relevant financial interests and dis-
closures pertaining to this manuscript.
Acknowledgment
This material is the result of work supported with resources and the
use of facilities at Hines, IL, and Greater Los Angeles, CA, VA
Healthcare Systems.
Appendix A. Supplementary data
Supplementary data related to this article can be found at https://
doi.org/10.1016/j.jpsychires.2018.08.023.
References
Ahmadi, N., Moss, L., Simon, E., Nemeroff, C.B., Atre-Vaidya, N., 2016. Efficacy and long-term
clinical outcome of comorbid posttraumatic stress disorder and major depressive disorder
after electroconvulsive therapy. Depress. Anxiety 33 (7), 640–647.
APA Task Force, 2001. APA Committee on Electroconvulsive Therapy: The Practice of
Electroconvulsive Therapy: Recommendations for Treatment, T.a.P.n.e.W. American
Psychiatric Press, Inc, DC.
Baker, G.R., MacIntosh-Murray, A., Porcellato, C., Dionne, L., Stelmacovich, K., Born, K., 2008.
Veterans Affairs New England Healthcare System (Veterans Integrated Service Network 1),
High Performing Healthcare Systems: Delivering Quality by Design. Longwoods Publishing,
Toronto, pp. 71–114.
Boscarino, J.A., 2006. Posttraumatic stress disorder and mortality among U.S. Army veterans 30
years after military service. Ann. Epidemiol. 16 (4), 248–256.
Bostwick, J.M., Pankratz, V.S., 2000. Affective disorders and suicide risk: a reexamination. Am.
J. Psychiatr. 157 (12), 1925–1932.
Bourgon, L.N., Kellner, C.H., 2000. Relapse of depression after ECT: a review. J. ECT 16 (1),
19–31.
Brown, E.D., Lee, H., Scott, D., Cummings, G.G., 2014. Efficacy of continuation/maintenance
electroconvulsive therapy for the prevention of recurrence of a major depressive episode in
adults with unipolar depression: a systematic review. J. ECT 30 (3), 195–202.
136
Journal of Psychiatric Research 105 (2018) 132–136
Dedert, E.A., Calhoun, P.S., Watkins, L.L., Sherwood, A., Beckham, J.C., 2010 Feb.
Posttraumatic stress disorder, cardiovascular, and metabolic disease: a review of the evi-
dence. Ann. Behav. Med. 39 (1), 61–78.
Dennis, P.A., Kimbrel, N.A., Sherwood, A., Calhoun, P.S., Watkins, L.L., Dennis, M.F., Beckham,
J.C., 2017. Trauma and autonomic dysregulation: episodic-versus systemic-negative affect
underlying cardiovascular risk in posttraumatic stress disorder. Psychosom. Med. 79 (5),
496–505.
Ebert, A., Jochum, T., Ritter, J., Boettger, M.K., Schulz, S., Voss, A., Bar, K.J., 2010. Does
parasympathetic modulation prior to ECT treatment influence therapeutic outcome? Prog.
Neuro-Psychopharmacol. Biol. Psychiatry 34 (7), 1174–1180.
Group, U.E.R., 2003. Efficacy and safety of electroconvulsive therapy in depressive disorders: a
systematic review and meta-analysis. Lancet 361 (9360), 799–808.
Gupta, S., Tobiansky, R., Bassett, P., Warner, J., 2008. Efficacy of maintenance electro-
convulsive therapy in recurrent depression: a naturalistic study. J. ECT 24 (3), 191–194.
Kemp, A.H., Quintana, D.S., Felmingham, K.L., Matthews, S., Jelinek, H.F., 2012. Depression,
comorbid anxiety disorders, and heart rate variability in physically healthy, unmedicated
patients: implications for cardiovascular risk. PLoS One 7 (2), e30777.
Martinez-Amoros, E., Cardoner, N., Galvez, V., Urretavizcaya, M., 2012. Effectiveness and
pattern of use of continuation and maintenance electroconvulsive therapy. Rev. Psiquiatía
Salud Ment. 5 (4), 241–253.
Navarro, V., Gasto, C., Torres, X., Masana, G., Penades, R., Guarch, J., Vazquez, M., Serra, M.,
Pujol, N., Pintor, L., Catalan, R., 2008. Continuation/maintenance treatment with nor-
triptyline versus combined nortriptyline and ECT in late-life psychotic depression: a two-
year randomized study. Am. J. Geriatr. Psychiatr. 16 (6), 498–505.
Rihmer, Z., Gonda, X., Fountoulakis, K.N., 2009. Suicide prevention programs through edu-
cation in the frame of healthcare. Psychiatr. Hung. 24 (6), 382–387.
Russell, J.C., Rasmussen, K.G., O'Connor, M.K., Copeman, C.A., Ryan, D.A., Rummans, T.A.,
2003. Long-term maintenance ECT: a retrospective review of efficacy and cognitive out-
come. J. ECT 19 (1), 4–9.
Servant, D., Logier, R., Mouster, Y., Goudemand, M., 2009. [Heart rate variability. Applications
in psychiatry]. Encephale 35 (5), 423–428.
Shelef, A., Mazeh, D., Berger, U., Baruch, Y., Barak, Y., 2015. Acute electroconvulsive therapy
followed by maintenance electroconvulsive therapy decreases hospital re-admission rates
of older patients with severe mental illness. J. ECT 31 (2), 125–128.
Tateishi, Y., Oda, S., Nakamura, M., Watanabe, K., Kuwaki, T., Moriguchi, T., Hirasawa, H.,
2007. Depressed heart rate variability is associated with high IL-6 blood level and decline
in the blood pressure in septic patients. Shock 28 (5), 549–553.
Trevino, K., McClintock, S.M., Husain, M.M., 2010. A review of continuation electroconvulsive
therapy: application, safety, and efficacy. J. ECT 26 (3), 186–195.
Wang, Y., Hensley, M.K., Tasman, A., Sears, L., Casanova, M.F., Sokhadze, E.M., 2016. Heart
rate variability and skin conductance during repetitive TMS course in children with autism.
Appl. Psychophysiol. Biofeedback 41 (1), 47–60.
Yrondi, A., Sporer, M., Peran, P., Schmitt, L., Arbus, C., Sauvaget, A., 2018. Electroconvulsive
therapy, depression, the immune system and inflammation: a systematic review. Brain
Stimul 11 (1), 29–51.