Efficacy of ECT in chronic, severe, antidepressant- and CBT-refractory PTSD: an open, prospective study

Treatment options are limited in patients with severe, chronic, posttraumatic stress disorder (PTSD). There is little information on the use of electroconvulsive therapy (ECT) for PTSD.

Between January 1, 2005, and December 31, 2005, all consenting adults (n=20) with severe, chronic, extensively antidepressant-refractory PTSD were prospectively treated with a fixed course of 6 bilateral ECT treatments administered on an outpatient basis at a twice-weekly frequency. The primary outcome measure was improvement on the Clinician-Administered Posttraumatic Stress Disorder Scale (CAPS). Baseline refractoriness was defined as a failure to respond to an adequate course of at least 4 different antidepressant drugs along with 12 sessions of cognitive behavior therapy. Response to ECT was defined as at least 30% attenuation of CAPS ratings, and remission as an endpoint CAPS score of 20 or less. After ECT, patients were prescribed sertraline (100-150 mg/day) or mirtazapine (15-30 mg/day).

All but 3 patients completed the ECT course. An intent-to-treat analysis (n=20) showed statistically and clinically significant improvement in the sample as a whole: CAPS scores decreased by a mean of 34.4%, and depression scores by a mean of 51.1%. Most of the improvement in CAPS and depression ratings developed by the third ECT; that is, by day 10 of treatment, itself. The improvement in CAPS ratings was independent of the improvement in depression ratings; and improvement in CAPS did not differ significantly between patients with less severe vs more severe baseline depression. The response rate was 70%; no patient remitted. In the completer analysis (n=17), mean improvements were 40% and 57% for CAPS and depression ratings, respectively, and the response rate was 82%. Treatment gains were maintained at a 4-6 month follow-up.

ECT may improve the core symptoms of PTSD independently of improvement in depression, and may therefore be a useful treatment option for patients with severe, chronic, medication- and CBT-refractory PTSD.