A Global Delphi-Based Expert Consensus on Relapse Prevention Strategies Following Successful Electroconvulsive Therapy for Major Depressive Disorder

OBJECTIVE: Electroconvulsive therapy (ECT) is a highly effective treatment for depression, yet relapse rates up to 50% within a year are reported. Studies have examined ECT, pharmacological, and nonpharmacological relapse prevention strategies, and although current guidelines provide general recommendations, no consensus-based or operationalized guidance exists regarding optimal relapse prevention after successful ECT for major depressive disorder. The aims of this study were to identify relapse prevention strategies commonly implemented after ECT, to evaluate their perceived effectiveness among international ECT experts, and to establish consensus-based personalized clinical recommendations. METHODS: A multiround Delphi study was conducted with a global panel of 18 ECT experts. Consensus was defined as ≥80% agreement on Likert-scale responses. RESULTS: Consensus was reached on key clinical factors influencing relapse prevention, including treatment resistance, psychiatric comorbidities, and prior ECT response. An essential relapse prevention strategy, namely, pharmacotherapy with lithium and an antidepressant (a tricyclic antidepressant, venlafaxine, or a prior effective antidepressant), was endorsed for all patients. Continuation ECT by means of tapering, rather than abrupt cessation, was recommended for patients at high risk of relapse and with severe or psychotic depression. Psychotherapy was considered beneficial as an adjunctive rather than a standalone treatment. No consensus was reached on the role of repetitive transcranial magnetic stimulation, esketamine, or optimal treatment duration of relapse prevention beyond 6 months. CONCLUSIONS: This Delphi study provides expert-based guidance on relapse prevention following successful ECT for major depressive disorder. While pharmacotherapy and continuation ECT are core strategies, personalized adjustments based on clinical risk factors remain essential. Further empirical research is needed to refine guidelines and improve long-term outcomes.