REGULAR ARTICLES The Influence of Age on the Response of Major Depression to Electroconvulsive Therapy A C.O.R.E. Report M. Kevin O’Connor, M.D., Rebecca Knapp, Ph.D. Mustafa Husain, M.D., Teresa A. Rummans, M.D. Georgios Petrides, M.D., Glenn Smith, Ph.D. Martina Mueller, M.S., Karen Snyder, B.S. Hilary Bernstein, M.S., A. John Rush, M.D. Max Fink, M.D., Charles Kellner, M.D. As part of a C.O.R.E., multi-site longitudinal study comparing continuation electroconvulsive therapy (ECT) vs. continuation pharmacotherapy, the authors determined the response of 253 patients with major depression to acute-phase, bilateral ECT by use of the 24-item Hamilton Rating Scale for Depression. Remission rates for three age-groups, Ն65 years; 46–64 years; and Յ45 years, were 90 percent, 89.8 percent, and 70 percent, respectively. Age, as a continuous variable, positively influenced response to treatment. Bilateral, dose-titrated ECT is a highly effective acute treatment for major depression, and older age confers a greater likelihood of achieving remission. (Am J Geriatr Psychiatry 2001; 9:382–390) M ajor depressive disorder (MDD) causes significant morbidity and mortality across the age continuum,1 but may be most problematic in elderly patients, where it often goes unrecognized and undertreated.2,3 In addition to its profoundly negative impact on quality of life and the associated risk of suicide, major depression may contribute to premature mortality in elderly patients because it diminishes adherence to necessary medical treatment and compounds the greater burden of medical illness borne by those over 65. Electroconvulsive therapy (ECT) is an effective treatment modality that is commonly used in geriatric patients with major depression.4 Controversy has existed regarding whether or not ECT is as effective and well tolerated in elderly patients as it is in younger ones. To summarize, the retrospective studies5–9 contradict one another on this issue. Two recent prospective trials,10,11 however, have found at least equivalent response rates between these age-groups. The purpose of the present article is to examine the influence of age on response to an acute course of ECT. This work is based on results from 253 depressed Received April 5, 2001; revised May 25, 2001; accepted June 4, 2001. From the Mayo Clinic, Rochester, Minnesota. Address correspondence to Dr. O’Connor, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. Copyright ᭧ 2001 American Association for Geriatric Psychiatry 382 Am J Geriatr Psychiatry 9:4, Fall 2001 O’Connor et al. patients participating in the CORE Continuation ECT vs. Pharmacotherapy Trial, in which standardized assessments and uniform ECT parameters were utilized. Specifically, we sought to confirm our hypothesis that age confers a greater responsivity to acute-phase ECT in major depression. METHODS Design Overview This study protocol was reviewed and approved by the Institutional Review Board of all four sites. Written informed consent was obtained from each participant. The Consortium for Research in ECT (CORE) Continuation ECT vs. Pharmacotherapy Trial, begun in February 1997, is an ongoing, 5-year, multicenter, NIH-funded trial of the efficacy and safety of continuation ECT in patients with MDD. In the first phase of the trial (Phase I), patients receive acute ECT three times per week; patients who meet strict Remitter criteria and who remain remitted for 1 week are randomly assigned to receive continuation ECT or continuation pharmacotherapy (nortriptyline plus lithium; Phase II) and followed for 6 months to evaluate relapse. The 24-Item Hamilton Rating Scale for Depression (24-item Ham-D)12 is administered 1–3 days after each ECT treatment. The primary outcome for Phase I is remission status and for Phase II is relapse status. The participating clinical sites are the Medical University of South Carolina (MUSC) in Charleston, SC; Hillside Hospital North Shore/Long Island Jewish Health System (New York); Mayo Clinic (Rochester, MN), and University of Texas Southwestern Medical Center (Dallas). Patients were included if they met criteria for major depression as the principal diagnosis on the basis of the structured interview for DSM-IV Axis I diagnoses (SCIDIV)13 and had a score of 20 or higher on the 24-item Ham-D. Patients with the following diagnoses were excluded on the basis of history, clinical examination, and performance on the SCID: schizoaffective disorder, schizophrenia, bipolar disorder, substance dependence within the past 12 months, neurologic disease or brain injury, preexisting delirium, comorbid medical conditions contraindicating ECT or Nor-Li administration, and previous treatment failure in the index episode on the combination of a heterocyclic antidepressant and lithium. Patients thought likely to have dementia were ex- Am J Geriatr Psychiatry 9:4, Fall 2001 cluded on the basis of a Mini-Mental State Exam (MMSE)14 score below 20. Among the group of 326 subjects screened for participation (i.e., assigned a study number) before January 2000, 73 were eliminated because they met exclusion criteria (16%, MDD not primary diagnosis; 12%, 24-item Ham-D Ͻ20; 14%, delirium, dementia, amnestic disorders, or substance dependence within 12 months; 12%, contraindicated comorbid general medical conditions; 8%, refused informed consent; 7%, neurologic disease or brain injury; 31%, other exclusion categories or category not specified). Study Sample As of January 1, 2000, 253 subjects had participated in the acute ECT treatment phase (Phase I). Of these 253 patients, 217 completed Phase I as prescribed by the protocol (Completer sample). The patients who dropped out (premature exits) withdrew for a variety of reasons including refusal of further treatments (8/ 36), psychiatric or other intercurrent medical events (4/ 36), treatment side effects (16/36; confusion and memory impairment, headaches, nausea, anxiety), and protocol violations (8/36). The final mean 24-item HamD score for those who exited prematurely was 19.2( 9.6עn ,)63סvs. 8.1( 3.6עn )712סfor the study Completers. ECT Procedures The Thymatron DGX ECT device (Somatics, Inc., Lake Bluff, IL) was used for the administration of ECT. A standardized dose titration method was used to determine seizure threshold. All treatments were administered using the bi-temporal electrode placement. After seizure threshold was determined at the first treatment session, all subsequent treatments were delivered at 1.5 times this energy setting. Definition of Remitter Status For Phase I, the primary outcome is remission status, defined as a decrease from baseline in 24-item Ham-D scores of at least 60% and a final 24-item Ham-D of 10 or less on two consecutive occasions. Treatment Responders were those who showed at least at 50% decrease from baseline in 24-item Ham-D scores, regardless of final 24-item Ham-D score. Non-Remitters 383 Age and Response to ECT were patients given at least 10 treatments without achieving remission status. Analysis Sets We carried out all analyses with two analysis sets: a) Completers (n ,)712סcomprising all subjects who either remitted or remained on study through the required 10 ECT treatment sessions without achieving full remission status (Non-Remitters); b) full analysis set (analogous to an intent-to-treat sample), comprising all subjects who agreed to participate in the study and who had at least one ECT and one post-baseline measurement (N.)352ס Statistical Analyses The primary dependent variables were remission status and 24-item Ham-D scores; the primary independent variable was patient age. In separate analyses, age was treated as a continuous variable and as a categorical variable having three categories: 18–45, 46–64, and 65– 85. This categorization was selected to equalize approximately the sample size across the groups and because it can be considered clinically as roughly corresponding to a younger group, a middle-aged group, and an elderly group. Analyses were repeated with the oldest age category separated into Young-Old (65–74 years) and OldOld (Ͼ74 years). The results across all categories of comparison for the oldest-old subjects were similar to those for the young-old; hence, results will be reported only for the combined older category (65–85 years). To evaluate the comparability of the age-groups with respect to baseline and demographic characteristics, we used one-way analysis of variance (ANOVA) for continuous variables and chi-square tests for categorical variables. For the dichotomous outcome (Remitter/Nonremitter), chi-square analyses were used to evaluate the simple (unadjusted) relationship of age-group to the dichotomous outcome (Remitter/Nonremitter). We compared end-of-treatment 24-item Ham-D (final 24-item Ham-D) and change from baseline in total 24-item Ham-D scores across age-groups by use of oneway ANOVA, followed by post-hoc pairwise comparisons (Tukey’s Honestly Significant Difference [HSD] procedure), if warranted. We also carried out multivariate regression analyses, using change in 24-item HamD as the dependent variable, age as the primary inde- 384 pendent variable, with psychosis status (psychotic depression vs. nonpsychotic depression), initial severity (24-item Ham-D at baseline), age at onset of depression, number of psychiatric hospitalizations, and number of previous episodes as additional candidate covariables to evaluate the relationship between change in 24-item Ham-D and age-adjusted for the potential confounding or moderator effects of the covariables. All significance tests were two-tailed and used a significance level of 0.05. Missing data. For analyses involving the full analysis set (N ,)352סwe assigned to premature exits (dropouts) the worst-case value of Nonremitter. For the endof-treatment 24-item Ham-D analyses, we considered the final value observed for 24-item Ham-D total score before exit as the observed end-of-treatment value for premature exits. The average end-of-treatment 24-item Ham-D for premature exits was not significantly different across the three age-groups (Young: 20.5 ;4.8עMiddle: 17.5 ;0.5עOlder: 17.7 ;1.4עP ;74.0סone-way ANOVA), and the reasons for premature exits were similar across these groups. RESULTS Baseline Demographic, Clinical, and Treatment Characteristics Table 1 presents demographic, clinical, and treatment characteristics for the total sample and for the three age-groups. The average age of the total sample (N )352סwas 56 2.61עyears, with 66% of the sample being women and 90.1%, white, reflecting the demographics of the U.S. population who currently are referred for ECT. The proportion of patients with psychotic depression was 30% for the total group, with 24.1% in the youngest group vs. 35.5% in the oldest group (P ;72.0סchi-square test). The age at onset of depression was 40.8 7.91עyears for the total group and ranged from 25.6 5.9עyears for the youngest group to 57.5 8.71עyears for the oldest group. On average, the youngest group had significantly more previous episodes of depression (3.6 )9.6עcompared with the middle (2.4 )5.3עand the older groups (1.6;4.2ע P ;130.0סone-way ANOVA) with 55.1% of the youngest reporting more than two previous episodes, vs. 45% of the middle and 38.8% of the oldest groups. Approxi- Am J Geriatr Psychiatry 9:4, Fall 2001 O’Connor et al. mately 29% of the middle and older groups reported no previous episodes of depression, vs. 23% of the youngest group (P ;546.0סchi-square test). The average number of psychiatric hospitalizations for any psychiatric illness (young: 2.6 ;0.2עmiddle: 2.3 ;1.2עolder: 2.2 )5.1עand the proportion with more than two psychiatric hospitalizations (young: 62.5%; middle: 57.7%; older: 63.7%) were similar across the age-groups. The average number of ECT treatments received by the total sample was 7.8 ,3.3עand was similar across the agegroups (young: 7.5עSD3.3; middle: 8.0 ;4.3עolder: 7.7 ;3.3עP ;86.0סone-way ANOVA). The severity of illness at baseline was similar for the young, middle, and older age-groups, with mean 24-item Ham-D baseline scores of approximately 35 across all groups (P;49.0ס one-way ANOVA). TABLE 1. Remission Status For the full analysis set (treating premature exits as Nonremitters), 75% of all patients reached full remission status (Table 2), requiring an average of 7.8 3.3עECT treatments. The rate of remission was higher in both the middle (86%) and older age-groups (80%) compared with the youngest group (57%; P ;4000.0סchi-square test). The proportion achieving full remission status was even more pronounced among those who completed the acute phase (n %78 ;)712סof all Completers reached full remission criteria, requiring an average of approximately eight ECT treatments (approximately 2.5 weeks of treatment). The differential remission rate across age-groups was also evident among study Completers, with approximately 90% in the middle and old- Demographic and baseline clinical and treatment characteristics for the total sample and for Young (18–45), Middle (46–64), and Older (65–85) age categories Variable Total Sample (N253) 18–45 (n79) 46–64 (n81) 65–85 (n93) Age, years P 56.2 ()2.61ע 37.3 ()1.7ע 54.7 ()4.5ע 73.8 ()6.5ע Gender, % women 66.4% (168/253) 66.6% (51/79) 64.2% (52/81) 70% (65/93) 0.669a Psychosis, % psychotic 30.4% (77/253) 24.1% (19/79) 30.9% (25/81) 35.5% (33/93) 0.266a 90.1% (228/253) 6.7% (17/253) 3.2% (8/253) 86.1% (68/79) 10.1% (8/79) 3.8% (3/79) 87.7% (71/81) 6.2% (5/81) 6.2% (5/81) 95.7% (89/93) 4.3% (4/93) 0% (0/93) 0.10b Age at illness onset, years 40.8 ()7.91ע 25.6 ()5.9ע 37.1 ()4.41ע 57.5 ()8.71ע Ͻ0.0001c n previous episodes % no previous episodes 2.5 ()6.4ע 27.4% (61/223) 45.7% (102/223) 3.6 ()9.6ע 23.2% (16/69) 55.1% (31/69) 2.4 ()5.3ע 29.0% (20/69) 44.9% (38/69) 1.6 ()4.2ע 29.4% (25/85) 38.8% (52/85) 0.031c 0.645 Length of current episode, years 0.95 ()9.1ע 0.96 ()0.2ע 0.88 ()5.1ע 1.00 ()1.2ע 0.905c n psychiatric hospitalizations 2.4 ()9.1ע (n)742ס 12.6% (31/247) 61.5% (152/247*) 2.6 ()0.2ע (n)87ס 12.8% (10/78) 62.5% (48/78) 2.3 ()1.2ע (n)87ס 14.1% (11/78) 57.7% (45/78) 2.2 ()5.1ע (n)19ס 11.0% (10/91) 63.7% (58/91) 0.393c 7.8 ()3.3ע 7.5 ()3.3ע 8.0 ()4.3ע 7.7 ()3.3ע 0.681c 125.0 ()0.66ע 86.2 ()8.93ע 125.5 ()5.85ע 157.2 ()1.27ע Ͻ0.0001c Race, % White Black Other % Ն two previous episodes No psychiatric hospitalizations, % Ն two psychiatric hospitalizations, % Total n ECT treatments Seizure threshold, in milliCoulombs 0.130 0.828d 0.695d Note: Values are mean (עstandard deviation) unless otherwise specified; ns do not always total 253 because of missing values for the variable. a From a 3 ( 2 ןPsychosis: Age-Group ןPsychosis status; Gender: Age-Group ןGender) chi-square test. b From a 3 ( 3 ןAge ןRace) chi-square test. c From a one-way analysis of variance comparing means across age categories. d From a 3 ( 2 ןAge ןHospitalization) chi-square test. Am J Geriatr Psychiatry 9:4, Fall 2001 385 Age and Response to ECT est age-groups remitting, compared with 75% in the youngest groups (Table 2; P ;300.0סchi-square test). 84% of all patients (N )352סexperienced at least a 50% reduction from baseline in 24-item Ham-D scores (treatment Responders), with the proportion of Responders ranging from 68% in the youngest group to approximately 90% in the middle and older age-groups (PϽ0.0001; one-way ANOVA; Table 2). Change in 24-item Ham-D. As shown in Figure 1, patients in all age-groups showed, on average, greater than a 20-point decrease in 24-item Ham-D scores over the course of acute-phase treatment. However, patients in the middle and older age-groups showed a greater decrease in 24-item Ham-D total scores over the acute treatment course than patients in the youngest group. Those in the youngest group had an average final 24item Ham-D of 12.7 ,3.9עcompared with an average TABLE 2. final 24-item Ham-D of 8.5 2.6עfor the older groups (PϽ0.0001; one-way ANOVA). Considering age as a continuous variable, the association between age and change in 24-item Ham-D was positive and highly significant (P .)8900.0סThis effect of age on 24-item HamD outcome remained significant in multiple-regression analyses after adjustment for psychosis status, initial severity (24-item Ham-D baseline), and number of previous episodes (multiple-regression analyses beta-coefficient for age ;90.0סP ;3100.0סmodel r2.)25.0ס Additional regression analyses that included clinical site and clinical site ןage interaction terms did not indicate a significant clinical site effect or a differential effect of age across clinical sites. Effect of presence of psychosis on age ןtreatment response relationship. Overall, illness severity at baseline as measured by total 24-item Ham-D appears to be Comparison of treatment response across Young (18–45), Middle (46–64), and Older (65–85) age-groups Age-Groups Response Overall 18–45 46–64 65–85 P Remitters, % (Completers; n)712ס 87.1% (189/217) 75.0% (45/60) 93.3% (70/75) 90.2% (74/82) 0.003e Remitters, %a,b (full analysis set; N)352ס 74.7% (189/253) 57.0% (45/79) 86.4% (70/81) 80.0% (74/93) 0.0004e Ն50% reduction in Ham-D, %c (full analysis set; N)352ס 83.8% (212/253) 68.4% (54/79) 91.4% (74/81) 90.3% (84/93) Ͻ0.0001e 35.0 ()0.7עh 35.0 ()7.6ע 34.8 ()8.6ע 35.2 ()5.7ע 0.942g Ham-D end (full analysis set; N)352ס 9.6 ()4.7עh 12.7 ()3.9ע 8.0 ()6.5ע 8.5 ()2.6ע Ͻ0.0001g Ham-D changed (full analysis set; N)352ס 25.4 ()8.9עh 22.3 ()9.9ע 26.8 ()9.8ע 26.6 ()8.9ע 0.003f 34.1 ()2.6ע (n)06ס 36.8 ()8.7ע (n)91ס 33.7 ()0.7ע (n)65ס 37.3 ()7.5ע (n)52ס 33.2 ()0.6ע (n)06ס 38.8 ()8.8ע (n)33ס 0.581g Ham-D end Nonpsychotic Psychotic 12.3 ()1.9ע 13.7 ()1.01ע 8.6 ()0.6ע 6.5 ()4.4ע 9.2 ()5.6ע 7.3 ()6.5ע 0.014g 0.001g Ham-D changed Nonpsychotic Psychotic 22.1 ()1.01ע 23.1 ()4.9ע 25.1 ()2.9ע 30.8 ()0.7ע 24.0 ()1.8ע 31.5 ()8.01ע 0.204g 0.006g a Ham-D baseline (full analysis set; N)352ס Comparison by psychosis status Ham-D baseline Nonpsychotic Psychotic 0.615g Note: Values are mean (עstandard deviation) unless otherwise specified. a RemitterסՆ50% reduction in Ham-D and final Ham-D Յ10. b For full analysis set, premature exits are considered Non-Remitters. c Percent reductionסHam-D change from baseline (Baseline-to-Final)/Ham-D baseline; last observed value used for dropouts. d Ham-D change from baseline (baseline to end of acute phase value). e From chi-square test. f From one-way analysis of variance comparing means across three Age categories. Pooled t-test Bonferroni-corrected P-values: Young vs. Middle, P ;900.0סYoung vs. Old, P ;210.0סMiddle vs. Older, PϾ0.9. g From one-way analysis of variance comparing means across three Age categories. h Mean (עstandard deviation). 386 Am J Geriatr Psychiatry 9:4, Fall 2001 O’Connor et al. slightly higher for the psychotic-depressed than for the nonpsychotic-depressed diagnostic groups, although the disparity did not reach statistical significance (Table 2). Despite the higher baseline levels, the final 24-item Ham-D values for the middle and older psychotic-depressed groups are lower than for the nonpsychoticdepressed group, giving a higher change from baseline score for these groups. Although the reduction in 24item Ham-D score is large (Ͼ22 points for all ages) among the nonpsychotic-depressed patients, the most pronounced effect of an acute ECT treatment course is seen among the older psychotic-depressed patients. The middle and older groups experienced, on average Ͼ30-point improvement in 24-item Ham-D over the treatment course, compared with a 23-point improvement for the youngest group (Table 2; P ;600.0סoneway ANOVA; with middle and older groups significantly higher than young; PϽ0.05; Tukey’s HSD post-hoc procedure). The trend toward increasing improvement FIGURE 1. with increasing age does not hold for the nonpsychoticdepressed groups (P ;402.0סone-way ANOVA; Table 2). DISCUSSION In 1984, a retrospective chart review authored by Karlinsky and Shulman5 examined their experience in administering ECT to a heterogeneous group of elderly patients with various diagnoses. They concluded that ECT in this population was not as effective and caused greater morbidity than in the younger age-group. Burke et al.,6 in another retrospective study, found that the rate of remission was lower, and the complication rate, particularly for cardiovascular events, was significantly higher in patients over the age of 60 who were given ECT. Cattan et al.7 performed a retrospective review of the response to ECT in a group of 39 patients over the age of 80 and compared it with that of 42 patients be- Comparison of mean baseline, final, and change from baseline 24-item Ham-D across Young (18–45), Middle (46–64), and Older (65–85) age-groups Note: N 352סpatients in the acute ECT treatment phase. Ham-DסHamilton Rating Scale for Depression. Baseline Ham-D: one-way ANOVA; F[2, 252] ;60.0סP .249.0סFinal Ham-D: one-way ANOVA; F[2, 252] ;4.01סP .1000.0סPost-hoc comparisons: Young vs. Middle, Bonferronicorrected P ;3000.0סYoung vs. Old, Bonferroni-corrected P ;200.0סMiddle vs. Old, Bonferroni-corrected P .9.0סChange from baseline: oneway ANOVA; F[2, 252] ;8.5סP .300.0סPost-hoc comparisons: Young vs. Middle, Bonferroni-corrected P ;900.0סYoung vs. Old, Bonferronicorrected P ;210.0סMiddle vs. Old, Bonferroni-corrected P.9.0ס Am J Geriatr Psychiatry 9:4, Fall 2001 387 Age and Response to ECT tween the ages of 65 and 80. They found that those over the age of 80 responded less well to treatment and had significantly more adverse outcomes, such as cardiovascular complications and falls. Response to treatment was judged from clinical commentary in the patients’ records. In contrast to these results, a number of retrospective studies have indicated more positive outcomes in elderly patients. Tomac et al.8 examined the Mayo Clinic experience in ECT treatment of 34 patients over the age of 85. Response to treatment, based on chart reviews, and non-blind 24-item Ham-D ratings performed during the course of treatment revealed that ECT was safe and effective with a variety of depressive disorders in this age-group. The most common complication was transient post-ECT confusion. Likewise, Gormley et al.9 found ECT to be safe and effective in patients over the age of 75, with 85 percent of their subjects obtaining marked or moderate improvement. The most common adverse events were confusion and hypomania, which, in virtually all cases, resolved within 2 weeks of treatment completion. In the first of two prospective comparison, Wilkinson et al.10 compared the response to ECT (as defined by a 50% reduction in the Montgomery-Asberg Depression Rating Scale) of four age-groups with DSM-III-R MDD and found that the response rate was 72 percent in patients over the age of 75 and only 54 percent in the younger age-group. Of particular note, they observed a concomitant increase in all age categories in MMSE performance 72 hours after completion of treatment. In a well-designed prospective study using standardized diagnostic criteria, near-uniform treatment across age-groups, and carefully measured outcome criteria, Tew et al.11 reported the comparative response of 268 patients, separating them into categories of “oldold” (age Ͼ75 years), “young-old” (age 60–74), and “adults” (age Յ59). They measured the 24-item Ham-D response of these age-groups to dose-titrated unilateral or bilateral ECT administered at 21⁄2 times the determined seizure threshold. The response of the old-old subjects was intermediate (67%) between that of adults (54%) and young-old (73%). It is noteworthy that the younger patients had a longer length of illness and were more resistant to heterocyclic antidepressant medication than either of the older age cohorts, two factors associated with diminished responsivity to ECT in the studies of Sackeim et al.15 and Prudic et al.16 388 The most intriguing finding of our study is the superior antidepressant response of the elderly patients to ECT as compared with the younger population—90% vs. 64%. One possible explanation may be that the influence of age on response to ECT is confounded by the presence of psychosis. The observed superior response of the elderly patients to ECT may be a function of the higher percentage of patients with psychotic depression seen in the older group. Among the nonpsychotically-depressed patients, the response to ECT, although high for all age-groups, was not significantly affected by age. Among the psychotically-depressed patients, however, there was a strong and statistically significant positive association between age and response to treatment. This differential effect of age on ECT response for psychotic and nonpsychotic patients may partially explain previously reported conflicting results. That is, failure to find an age effect in some studies may be attributable to the particular mix of psychotic- and nonpsychoticdepressed patients in a given sample of study participants. However, the presence of psychosis alone may not account completely for the higher response to ECT among the older age-groups. The earlier age at onset and the greater number of lifetime episodes observed in our younger age-groups, two factors generally thought to reflect the severity of depression, may be additional factors contributing to the different responsivity reported here. There are several limitations to this study. We did not assess Axis II psychopathology in the three agegroups. Personality disorder has been associated with diminished responsivity to antidepressant treatment and theoretically could have influenced treatment outcome. Although efforts were made to assess the relative resistance to previous antidepressant drug therapy in these populations, these data are incomplete and could not be analyzed at this time. They may appear in future C.O.R.E. reports. The most important limitation pertains to the measuring of treatment side effects. Because the focus of this NIMH-sponsored investigation was on continuation treatment, we conducted limited assessment of adverse events during Phase I, aside from the monitoring of the patients by the clinicians caring for them. However, the dropout rates across all three groups due to treatment side effects were statistically equivalent. Taken together with the study of Tew et al.,11 two well-designed, prospective trials involving 521 patients with MDD have now shown that there is a statistically Am J Geriatr Psychiatry 9:4, Fall 2001 O’Connor et al. significant superior response of older patients with major depression to ECT. For those over the age of 65 completing this study, the rate of remission was 90%, with those in the old-old group (over 75 years of age) having rates similar to those in the 65–74 group. This remission rate compares favorably with most treatments given in medicine. There are important differences between our study and that of Tew et al.;11 68% of their patients received unilateral treatment delivered at 21⁄2 times the determined seizure threshold. We treated all our patients with bilateral electrode placement at 11⁄2 times seizure threshold; 39% of the patients (87/223) who, they reported, were initially given unilateral treatments failed to respond to a minimum of five such treatments and required conversion to bilateral lead placement. In the Tew study, parameters of treatment were selected by the clinicians caring for these patients, and the end result of choosing such parameters was that 39% required an average of approximately 12.8 treatments and did not achieve as high a rate of remission as those who participated in our study, who were given an average of 7.4 treatments. Thus, technical treatment issues substantially influenced the length and expense of treatment. Solely from the standpoint of efficacy, our study would argue for the use of bilateral treatment at 11⁄2 times seizure threshold. Overall, these parameters resulted in a significantly higher remission rate and fewer treatments to achieve remission status. A number of studies have suggested that the neurobiology of depression may be different in elderly patients. Musetti et al.17 and Brodaty et al.18 have reported that elderly patients with depression are less likely to have a positive family history of mood disorder, suggesting that genetic factors are less important in geriatric depression. Alexopoulos et al.19 have postulated that there is a subset of geriatric patients who experience major depression as a result of cerebrovascular disease, particularly if it disrupts prefrontal brain circuitry. Coffey et al.20 have found more diffuse or confluent subcortical hyperintensities on brain MRI scans in geriatric MDD patients, as compared with younger patients, with MDD. Finally, Fink21 has hypothesized that ECT is effective through its stimulatory effect on the hypothalamus and by causing repetitive secretion of regulatory neuropeptide such as corticotropin-releasing factor; Fink (in an unpublished letter, 2001) also posited that neuroendocrine dysfunction is possibly more common in elderly patients. The findings in this study of the greater frequency of psychotic features and a substantially higher responsivity to ECT in older patients as compared with younger patients, would also support a different pathophysiology of depression in elderly patients. Further studies designed to examine the basic biology of a positive therapeutic response to ECT in older patients as compared with that of younger patients would add to our understanding of the biology of depression in elderly patients. The research reported in this article was supported by a grant from the National Institutes of Health (MH 55484) awarded to Consortium on Research in ECT. References 1. 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