Expert Guide to Relapse Prevention After ECT

Eighteen international experts weigh in

STUDY: Rovers JJE et al, American Journal of Psychiatry 2026

STUDY TYPE: Delphi expert consensus

FUNDING: Independent

Background

Electroconvulsive therapy (ECT) is one of the most effective treatments for depression, particularly when psychotic features are present. The problem is that about half of patients relapse within a year, most within six months. This expert panel offers advice on how to keep patients well.

The Study

• 18 international ECT experts (17 psychiatrists, one psychologist) from centers across North America, Europe, South America, Africa, Asia, and Australia.
• Consensus was set at 80% agreement, with response rates of 100% in rounds 1 and 2, dropping to 80% in rounds 3 and 4.

Results

Every patient who responds to ECT needs some form of relapse prevention. The essential strategy is to continue or start pharmacotherapy for at least six months. The best evidence is for lithium as an add-on to antidepressants (the studies used nortriptyline or venlafaxine), or lithium alone if they have bipolar disorder.

For higher-risk patients, taper continuation ECT rather than stopping abruptly. High risk includes many patients who present for ECT:

• Highly recurrent depression
• Prior relapse after ECT
• Heavy psychiatric comorbidity
• High levels of treatment resistance
• Severe or psychotic depression

Tapering typically means weekly sessions for about four weeks, then spacing out based on how the patient is doing.

Patients who can’t tolerate medication side effects should use continuation or maintenance ECT instead. Comorbid personality or trauma-related disorders call for psychotherapy added to pharmacotherapy, not medication alone. If relapse happens despite adequate pharmacotherapy, maintenance ECT is the next step.

No consensus emerged on rTMS, esketamine, how to handle ongoing psychosocial stressors, or how long to continue treatment beyond six months.

Practice Implications

1. Lithium is not the most effective acute therapy for depression, but it is one of the best treatments for preventing depression. That includes relapses in recurrent and bipolar depression, re-admissions after hospitalization, and prevention after ECT.
2. Learn more ways to guide patients through ECT as a general psychiatrist in our Carlat interview with Vaughn McCall.