Rivastigmine for ECT-included Cognitive Adverse effects in Late Life Depression

The RECALL project is a double blind placebo controlled crossover trial at the department of old age psychiatry at GGZ inGeest.

Electroconvulsive therapy (ECT) is the most effective treatment for severe depressions. Unfortunately, several cognitive side effects with a large pallet of different manifestations and impact often occur. The side effects that are known:

• Firstly, postictal agitation (PIA). PIA with ia motor restlessness and panic like behaviour directly after ECT lasting 5 minutes till one hour,
• Mildly general disorientation recovering within 1-2 hours after ECT,
• Anterograde memory deficits and retrograde amnesia (both mostly reversible after a few weeks till several months) are well known.
• Finally, interictal delirium characterised by severe confusion. This can appear separately form the postictal disorientation mostly in elderly individuals (Selvaraj, 2012). And it could take several days to weeks to resolve. In particular this effect may result in a premature abandoning of ECT. And hence failure to achieve remission of the depressive disorder.

Treatment with an acetylcholinesterase inhibitor (i.e. rivastigmine) might be useful for the prevention or reversion of the interictal delirium as well. This treatment has a beneficial effect on cognition in persons with mild to moderate Alzheimer’s dementia. And it has the potential beneficial effect on memory deficits in ECT-treated persons with schizophrenia (Stryjer et al., 2012, and either major depressive disorder, bipolar or schizoaffective disorder (Matthews et al., 2013).

Study design

Therefore a randomised double blind placebo controlled crossover trial was designed. The trial is embedded in a large cohort-study on ECT-patients. Aiming to investigate whether rivastigmine treatment has a positive effect on the severity and duration of the interictal delirium. We hypothesize, that rivastigmine addition during ECT can diminish the interictal delirium, induced by ECT. 

Aim of the study

This study’s main aim is twofold. The first aim is to investigate whether rivastigmine can be used as a novel treatment to reduce ECT-induced interictal delirium. The second aim is to gain further insight into differences in determinants between inter-ictal delirium and adjacent cognitive disturbances induced by ECT, including post-ictal agitation and mild general disorientation of short duration.

When a patient fulfills the inclusion criteria for the trial, a transdermal rivastigmine patch (group A) or placebo patch (group B) will be applied the evening before ECT treatment. The patch will be removed 24hrs after application. After two ECT sessions, group A will receive placebo treatment for two sessions and group B will receive a rivastigmine patch for two sessions.