What do psychiatrists mean by medication resistance as an indication for electroconvulsive therapy?

Resistance to antidepressant medication is the commonest stated indication for electroconvulsive therapy (ECT) by psychiatrists, but what this means in practice has not been described. Our aims were to survey what antidepressant drug treatment had been prescribed to patients before they underwent ECT and to what extent this treatment would satisfy operational criteria for adequate antidepressant drug treatment used in ECT research.

The survey was conducted prospectively among 37 depressed patients referred for a new course of bilateral ECT and where antidepressant medication resistant was identified as the indication for ECT.

Only half the sample had been prescribed more than one antidepressant drug, and only 38% had been prescribed any augmentation compound. Although the majority of patients were resistant to medication when rated by the older operational criteria, only half the sample met contemporary criteria for medication resistance.

The findings suggest a lack of agreement between clinicians and researchers in what constitutes medication resistance as a possible indication for ECT. It will take some time to establish if the revised UK Royal College of Psychiatrists ECT Handbook will encourage more intensive medical treatment of depressive illness before the use of ECT.