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Medically reviewed by Oliinyk Elizabeth Ivanovna, PharmD. Last updated on 10.04.2022
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KAPVAY® (clonidine hydrochloride) extended-release is indicated for the treatment of attention deficit hyperactivity disorder (ADHD) as monotherapy and as adjunctive therapy to stimulant medications.
General Dosing Information
KAPVAY is an extended-release tablet to be taken orally with or without food. Swallow tablets whole. Do not crush, chew, or break tablets because this will increase the rate of clonidine release.
Due to the lack of controlled clinical trial data and differing pharmacokinetic profiles, substitution of KAPVAY for other clonidine products on a mg-per-mg basis is not recommended.
Dose Selection
The dose of KAPVAY, administered either as monotherapy or as adjunctive therapy to a psychostimulant, should be individualized according to the therapeutic needs and response of the patient. Dosing should be initiated with one 0.1 mg tablet at bedtime, and the daily dosage should be adjusted in increments of 0.1 mg/day at weekly intervals until the desired response is achieved. Doses should be taken twice a day, with either an equal or higher split dosage being given at bedtime (see Table 1).
Table 1 : KAPVAY Dosing Guidance
| Total Daily Dose | Morning Dose | Bedtime Dose |
| 0.1 mg/day | 0.1 mg | |
| 0.2 mg/day | 0.1 mg | 0.1 mg |
| 0.3 mg/day | 0.1 mg | 0.2 mg |
| 0.4 mg/day | 0.2 mg | 0.2 mg |
Doses of KAPVAY higher than 0.4 mg/day (0.2 mg twice daily) were not evaluated in clinical trials for ADHD and are not recommended.
When KAPVAY is being added-on to a psychostimulant, the dose of the psychostimulant can be adjusted depending on the patient's response to KAPVAY.
Discontinuation
When discontinuing KAPVAY, the total daily dose should be tapered in decrements of no more than 0.1 mg every 3 to 7 days to avoid rebound hypertension.
Missed Doses
If patients miss a dose of KAPVAY, they should skip that dose and take the next dose as scheduled. Do not take more than the prescribed total daily amount of KAPVAY in any 24-hour period.
KAPVAY is contraindicated in patients with a history of a hypersensitivity reaction to clonidine. Reactions have included generalized rash, urticaria, and angioedema.
WARNINGS
Included as part of the PRECAUTIONS section.
PRECAUTIONS
Hypotension/Bradycardia
Treatment with KAPVAY can cause dose related decreases in blood pressure and heart rate. Measure heart rate and blood pressure prior to initiation of therapy, following dose increases, and periodically while on therapy. Titrate KAPVAY slowly in patients with a history of hypotension, and those with underlying conditions that may be worsened by hypotension and bradycardia; e.g., heart block, bradycardia, cardiovascular disease, vascular disease, cerebrovascular disease, or chronic renal failure. In patients who have a history of syncope or may have a condition that predisposes them to syncope, such as hypotension, orthostatic hypotension, bradycardia, or dehydration advise patients to avoid becoming dehydrated or overheated. Monitor blood pressure and heart rate, and adjust dosages accordingly in patients treated concomitantly with antihypertensives or other drugs that can reduce blood pressure or heart rate or increase the risk of syncope.
Sedation And Somnolence
Somnolence and sedation were commonly reported adverse reactions in clinical studies. In patients that completed 5 weeks of therapy in a controlled, fixed dose pediatric monotherapy study, 31% of patients treated with 0.4 mg/day and 38% treated with 0.2 mg/day versus 4% of placebo treated patients reported somnolence as an adverse event. In patients that completed 5 weeks of therapy in a controlled flexible dose pediatric adjunctive to stimulants study, 19% of patients treated with KAPVAY+stimulant versus 7% treated with placebo+stimulant reported somnolence. Before using KAPVAY with other centrally active depressants (such as phenothiazines, barbiturates, or benzodiazepines), consider the potential for additive sedative effects. Caution patients against operating heavy equipment or driving until they know how they respond to treatment with KAPVAY. Advise patients to avoid use with alcohol.
Rebound Hypertension
Abrupt discontinuation of KAPVAY can cause rebound hypertension. In adults with hypertension, sudden cessation of clonidine hydrochloride extended-release formulation treatment in the 0.2 to 0.6 mg/day range resulted in reports of headache, tachycardia, nausea, flushing, warm feeling, brief lightheadedness, tightness in chest, and anxiety. In adults with hypertension, sudden cessation of treatment with immediate-release clonidine has, in some cases, resulted in symptoms such as nervousness, agitation, headache, and tremor accompanied or followed by a rapid rise in blood pressure and elevated catecholamine concentrations in the plasma.
No studies evaluating abrupt discontinuation of KAPVAY in children with ADHD have been conducted; however, to minimize the risk of rebound hypertension, gradually reduce the dose of KAPVAY in decrements of no more than 0.1 mg every 3 to 7 days. Patients should be instructed not to discontinue KAPVAY therapy without consulting their physician due to the potential risk of withdrawal effects.
Allergic Reactions
In patients who have developed localized contact sensitization to clonidine transdermal system, continuation of clonidine transdermal system or substitution of oral KAPVAY therapy may be associated with the development of a generalized skin rash.
In patients who develop an allergic reaction from clonidine transdermal system, substitution of oral KAPVAY may also elicit an allergic reaction (including generalized rash, urticaria, or angioedema).
Cardiac Conduction Abnormalities
The sympatholytic action of clonidine may worsen sinus node dysfunction and atrioventricular (AV) block, especially in patients taking other sympatholytic drugs. There have been post-marketing reports of patients with conduction abnormalities and/or taking other sympatholytic drugs who developed severe bradycardia requiring IV atropine, IV isoproterenol, and temporary cardiac pacing while taking clonidine. Titrate KAPVAY slowly and monitor vital signs frequently in patients with cardiac conduction abnormalities or patients concomitantly treated with other sympatholytic drugs.
Patient Counseling Information
Advise the patient to read the FDA-approved Patient Labeling (PATIENT INFORMATION)
Dosage And Administration
Advise patients that KAPVAY must be swallowed whole, never crushed, cut, or chewed, and may be taken with or without food. When initiating treatment, provide dosage escalation instructions.
Missed Dose
If patients miss a dose of KAPVAY, advise them to skip the dose and take the next dose as scheduled and not to take more than the prescribed total daily amount of KAPVAY in any 24-hour period.
Hypotension/Bradycardia
Advise patients who have a history of syncope or may have a condition that predisposes them to syncope, such as hypotension, orthostatic hypotension, bradycardia, or dehydration, to avoid becoming dehydrated or overheated.
Sedation And Somnolence
Instruct patients to use caution when driving a car or operating hazardous machinery until they know how they will respond to treatment with KAPVAY. Also advise patients to avoid the use of KAPVAY with other centrally active depressants and with alcohol.
Rebound Hypertension
Advise patients not to discontinue KAPVAY abruptly.
Allergic Reactions
Advise patients to discontinue KAPVAY and seek immediate medical attention if any signs or symptoms of a hypersensitivity reaction occur, such as generalized rash, urticaria, or angioedema.
Nonclinical Toxicology
Carcinogenesis, Mutagenesis And Impairment Of Fertility
Clonidine HCl was not carcinogenic when administered in the diet of rats (for up to 132 weeks) or mice (for up to 78 weeks) at doses of up to 1620 (male rats), 2040 (female rats), or 2500 (mice) mcg/kg/day. These doses are approximately 20, 25, and 15 times, respectively, the maximum recommended human dose (MRHD) of 0.4 mg/day on a mg/m² basis.
There was no evidence of genotoxicity in the Ames test for mutagenicity or mouse micronucleus test for clastogenicity.
Fertility of male or female rats was unaffected by clonidine HCl doses as high as 150 mcg/kg/day (approximately 3 times the MRHD on a mg/m² basis). In a separate experiment, fertility of female rats appeared to be adversely affected at dose levels of 500 and 2000 mcg/kg/day (10 and 40 times the MRHD on a mg/ m² basis).
Use In Specific Populations
Pregnancy
Pregnancy Category C
Risk Summary
There are no adequate or well-controlled studies with KAPVAY in pregnant women. In animal embryofetal studies, increased resorptions were seen in rats and mice administered oral clonidine hydrochloride from implantation through organogenesis at 10 and 5 times, respectively, the maximum recommended human dose (MRHD). No embryotoxic or teratogenic effects were seen in rabbits administered oral clonidine hydrochloride during organogenesis at doses up to 3 times the MRHD. KAPVAY should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Animal Data
Oral administration of clonidine hydrochloride to pregnant rabbits during the period of embryo/fetal organogenesis at doses of up to 80 mcg/kg/day (approximately 3 times the oral maximum recommended daily dose [MRHD] of 0.4 mg/day on a mg/m² basis) produced no evidence of teratogenic or embryotoxic potential. In pregnant rats, however, doses as low as 15 mcg/kg/day (1/3 the MRHD on a mg/m² basis) were associated with increased resorptions in a study in which dams were treated continuously from 2 months prior to mating and throughout gestation. Increased resorptions were not associated with treatment at the same or at higher dose levels (up to 3 times the MRHD) when treatment of the dams was restricted to gestation days 6-15. Increases in resorptions were observed in both rats and mice at 500 mcg/kg/day (10 and 5 times the MRHD in rats and mice, respectively) or higher when the animals were treated on gestation days 1-14; 500 mcg/kg/day was the lowest dose employed in this study.
Nursing Mothers
Clonidine hydrochloride is present in human milk. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for KAPVAY and any potential adverse effects on the breastfed child from KAPVAY or from the underlying maternal condition. Exercise caution when KAPVAY is administered to a nursing woman.
Pediatric Use
The safety and efficacy of KAPVAY in the treatment of ADHD have been established in pediatric patients 6 to 17 years of age. Use of KAPVAY in pediatric patients 6 to 17 years of age is supported by three adequate and well-controlled studies; a short-term, placebo-controlled monotherapy trial, a short-term adjunctive therapy trial and a longer-term randomized monotherapy trial. Safety and efficacy in pediatric patients below the age of 6 years has not been established.
Juvenile Animal Data A study was conducted in which young rats were treated orally with clonidine hydrochloride from day 21 of age to adulthood at doses of up to 300 mcg/kg/day, which is approximately 3 times the maximum recommended human dose (MRHD) of 0.4 mg/day on a mg/m² basis. A slight delay in onset of preputial separation (delayed sexual maturation) was seen in males treated with the highest dose (with a no-effect dose of 100 mcg/kg/day, which is approximately equal to the MRHD), but there were no drug effects on fertility or on other measures of sexual or neurobehavioral development.
Renal Impairment
The impact of renal impairment on the pharmacokinetics of clonidine in children has not been assessed. The initial dosage of KAPVAY should be based on degree of impairment. Monitor patients carefully for hypotension and bradycardia, and titrate to higher doses cautiously. Since only a minimal amount of clonidine is removed during routine hemodialysis, there is no need to give supplemental KAPVAY following dialysis.
The following serious adverse reactions are described in greater detail elsewhere in labeling:
- Hypotension/bradycardia
- Sedation and somnolence
- Rebound hypertension
- Allergic reactions
- Cardiac Conduction Abnormalities
Clinical Trial Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
Two KAPVAY ADHD clinical studies (Study 1, CLON-301 and Study 2, CLON-302) evaluated 256 patients in two 8-week placebo-controlled studies.
A third KAPVAY ADHD clinical study (Study 3, SHN-KAP-401) evaluated 135 children and adolescents in a 40- week placebo-controlled randomized-withdrawal study.
Study 1: Fixed-dose KAPVAY Monotherapy
Study 1 (CLON-301) was a short-term, multi-center, randomized, double-blind, placebo-controlled study of two fixed doses (0.2 mg/day or 0.4 mg/day) of KAPVAY in children and adolescents (6 to 17 years of age) who met DSM-IV criteria for ADHD hyperactive or combined inattentive/hyperactive subtypes.
Most Common Adverse Reactions (incidence of ≥ 5% and at least twice the rate of placebo): somnolence, fatigue, irritability, insomnia, nightmare, constipation, dry mouth.
Adverse Events Leading to Discontinuation of KAPVAY –Five patients (7%) in the low dose group (0.2 mg), 15 patients (20%) in the high dose group (0.4 mg), and 1 patient in the placebo group (1%) reported adverse reactions that led to discontinuation. The most common adverse reactions that led to discontinuation were somnolence and fatigue.
Commonly observed adverse reactions (incidence of ≥ 2% in either active treatment group and greater than the rate on placebo) during the treatment period are listed in Table 2.
Table 2 : Common Adverse Reactions in the Fixed-Dose Monotherapy Trial- Treatment Period (Study 1)
| Preferred Term | Percentage of Patients Reporting Event | ||
| KAPVAY 0.2 mg/day N=76 | KAPVAY 0.4 mg/day N=78 | Placebo (N=76) | |
| PSYCHIATRIC DISORDERS | |||
| Somnolence* | 38% | 31% | 4% |
| Nightmare | 4% | 9% | 0% |
| Emotional Disorder | 4% | 4% | 1% |
| Aggression | 3% | 1% | 0% |
| Tearfulness | 1% | 3% | 0% |
| Enuresis | 0% | 4% | 0% |
| Sleep Terror | 3% | 0% | 0% |
| Poor Quality Sleep | 0% | 3% | 1% |
| NERVOUS SYSTEM DISORDERS | |||
| Headache | 20% | 13% | 16% |
| Insomnia | 5% | 6% | 1% |
| Tremor | 1% | 4% | 0% |
| Abnormal Sleep-Related Event | 3% | 1% | 0% |
| GASTROINTESTINAL DISORDERS | |||
| Upper Abdominal Pain | 15% | 10% | 12% |
| Nausea | 4% | 5% | 3% |
| Constipation | 1% | 6% | 0% |
| Dry Mouth | 0% | 5% | 1% |
| GENERAL DISORDERS | |||
| Fatigue† | 16% | 13% | 1% |
| Irritability | 9% | 5% | 4% |
| CARDIAC DISORDERS | |||
| Dizziness | 7% | 3% | 5% |
| Bradycardia | 0% | 4% | 0% |
| INVESTIGATIONS | |||
| Increased Heart Rate | 0% | 3% | 0% |
| METABOLISM AND NUTRITION DISORDERS | |||
| Decreased Appetite | 3% | 4% | 4% |
| * Somnolence includes the terms “somnolence” and “sedation”. † Fatigue includes the terms “fatigue” and “lethargy”. | |||
Commonly observed adverse reactions (incidence of ≥ 2% in either active treatment group and greater than the rate on placebo) during the taper period are listed in Table 3.
Table 3 : Common Adverse Reactions in the Fixed-Dose Monotherapy Trial- Taper Period* (Study 1)
| Preferred Term | Percentage of Patients Reporting Event | ||
| KAPVAY 0.2 mg/day N=76 | KAPVAY 0.4 mg/day N=78 | Placebo (N=76) | |
| Abdominal Pain Upper | 0% | 6% | 3% |
| Headache | 5% | 2% | 3% |
| Gastrointestinal Viral | 0% | 5% | 0% |
| Somnolence | 2% | 3% | 0% |
| Heart Rate Increased | 0% | 3% | 0% |
| Otitis Media Acute | 1 3% | 1 0% | 1 0% |
| * Taper Period: 0.2 mg dose, week 8; 0.4 mg dose, weeks 6-8; Placebo dose, weeks 6-8 |
Study 2: Flexible-dose KAPVAY as Adjunctive Therapy to Psychostimulants
Study 2 (CLON-302) was a short-term, randomized, double-blind, placebo-controlled study of a flexible dose of KAPVAY as adjunctive therapy to a psychostimulant in children and adolescents (6 to 17 years) who met DSM-IV criteria for ADHD hyperactive or combined inattentive/hyperactive subtypes. during which KAPVAY was initiated at 0.1 mg/day and titrated up to 0.4 mg/day over a 3-week period. Most KAPVAY treated patients (75.5%) were escalated to the maximum dose of 0.4 mg/day.
Most Common Adverse Reactions (incidence of ≥ 5% and at least twice the rate of placebo): somnolence, fatigue, decreased appetite, dizziness.
Adverse Events Leading to Discontinuation –There was one patient in the CLON+STM group (1%) who discontinued because of an adverse event (severe bradyphrenia, with severe fatigue).
Commonly observed adverse reactions (incidence of ≥ 2% in the treatment group and greater than the rate on placebo) during the treatment period are listed in Table 4.
Table 4 : Common Adverse Reactions in the Flexible-Dose Adjunctive to Stimulant Therapy Trial- Treatment Period (Study 2)
| Preferred Term | Percentage of Patients Reporting Event | |
| KAPVAY+STM (N=102) | PBO+STM (N=96) | |
| PSYCHIATRIC DISORDERS | ||
| Somnolence* | 19% | 7% |
| Aggression | 2% | 1% |
| Affect Lability | 2% | 1% |
| Emotional Disorder | 2% | 0% |
| GENERAL DISORDERS | ||
| Fatigue† | 14% | 4% |
| Irritability | 2% | 7% |
| NERVOUS SYSTEM DISORDERS | ||
| Headache | 7% | 12% |
| Insomnia | 4% | 3% |
| GASTROINTESTINAL DISORDERS | ||
| Upper Abdominal Pain | 7% | 4% |
| RESPIRATORY DISORDERS | ||
| Nasal Congestion | 2% | 2% |
| METABOLISM AND NUTRITION DISORDERS | ||
| Decreased Appetite | 6% | 3% |
| CARDIAC DISORDERS | ||
| Dizziness | 5% | 1% |
| * Somnolence includes the terms: “somnolence” and “sedation”. † Fatigue includes the terms “fatigue” and “lethargy”. | ||
Commonly observed adverse reactions (incidence of ≥ 2% in the treatment group and greater than the rate on placebo) during the taper period are listed in Table 5.
Table 5 : Common Adverse Reactions in the Flexible-Dose Adjunctive to Stimulant Therapy Trial- Taper Period* (Study 2)
| Preferred Term | Percentage of Patients Reporting Event | |
| KAPVAY+STM (N=102) | PBO+STM (N=96) | |
| Nasal Congestion | 4% | 2% |
| Headache | 3% | 1% |
| Irritability | 3% | 2% |
| Throat Pain | 3% | 1% |
| Gastroenteritis Viral | 2% | 0% |
| Rash | 2% | 0% |
| * Taper Period: weeks 6-8 |
Adverse Reactions Leading to Discontinuation
Thirteen percent (13%) of patients receiving KAPVAY discontinued from the pediatric monotherapy study due to adverse events, compared to 1% in the placebo group. The most common adverse reactions leading to discontinuation of KAPVAY monotherapy treated patients were from somnolence/sedation (5%) and fatigue (4%).
Effect on Blood Pressure and Heart Rate
In patients that completed 5 weeks of treatment in a controlled, fixed-dose monotherapy study in pediatric patients, during the treatment period the maximum placebo-subtracted mean change in systolic blood pressure was -4.0 mmHg on KAPVAY 0.2 mg/day and -8.8 mmHg on KAPVAY 0.4 mg/day. The maximum placebo-subtracted mean change in diastolic blood pressure was -4.0 mmHg on KAPVAY 0.2 mg/day and -7.3 mmHg on KAPVAY 0.4 mg/day. The maximum placebo-subtracted mean change in heart rate was -4.0 beats per minute on KAPVAY 0.2 mg/day and -7.7 beats per minute on KAPVAY 0.4 mg/day.
During the taper period of the fixed-dose monotherapy study the maximum placebo-subtracted mean change in systolic blood pressure was +3.4 mmHg on KAPVAY 0.2 mg/day and -5.6 mmHg on KAPVAY 0.4 mg/day. The maximum placebo-subtracted mean change in diastolic blood pressure was +3.3 mmHg on KAPVAY 0.2 mg/day and -5.4 mmHg on KAPVAY 0.4 mg/day. The maximum placebo-subtracted mean change in heart rate was -0.6 beats per minute on KAPVAY 0.2 mg/day and -3.0 beats per minute on KAPVAY 0.4 mg/day.
Postmarketing Experience
The following adverse reactions have been identified during post-approval use of KAPVAY. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These events exclude those already mentioned in 6.1:
Psychiatric: hallucinations
Cardiovascular: Q-T prolongation
Symptoms
Clonidine overdose: hypertension may develop early and may be followed by hypotension, bradycardia, respiratory depression, hypothermia, drowsiness, decreased or absent reflexes, weakness, irritability and miosis. The frequency of CNS depression may be higher in children than adults. Large overdoses may result in reversible cardiac conduction defects or dysrhythmias, apnea, coma and seizures. Signs and symptoms of overdose generally occur within 30 minutes to two hours after exposure.
Treatment
Consult with a Certified Poison Control Center (1-800-222-1222) for up-to-date guidance and advice.
Clonidine is a known antihypertensive agent. By stimulating alpha2-adrenergic receptors in the brain stem, clonidine reduces sympathetic outflow from the central nervous system and decreases peripheral resistance, renal vascular resistance, heart rate, and blood pressure.
Single-dose Pharmacokinetics in Adults
Immediate-release clonidine hydrochloride and KAPVAY have different pharmacokinetic characteristics; dose substitution on a milligram for milligram basis will result in differences in exposure. A comparison across studies suggests that the Cmax is 50% lower for KAPVAY compared to immediate-release clonidine hydrochloride.
Following oral administration of an immediate release formulation, plasma clonidine concentration peaks in approximately 3 to 5 hours and the plasma half-life ranges from 12 to 16 hours. The half-life increases up to 41 hours in patients with severe impairment of renal function. Following oral administration about 40-60% of the absorbed dose is recovered in the urine as unchanged drug in 24 hours.
About 50% of the absorbed dose is metabolized in the liver. Although studies of the effect of renal impairment and studies of clonidine excretion have not been performed with KAPVAY, results are likely to be similar to those of the immediate release formulation.
The pharmacokinetic profile of KAPVAY administration was evaluated in an open-label, three-period, randomized, crossover study of 15 healthy adult subjects who received three single-dose regimens of clonidine: 0.1 mg of KAPVAY under fasted conditions, 0.1 mg of KAPVAY following a high fat meal, and 0.1 mg of clonidine immediate-release (Catapres®) under fasted conditions. Treatments were separated by one-week washout periods.
Mean concentration-time data from the 3 treatments are shown in Table 7 and Figure 1. After administration of KAPVAY, maximum clonidine concentrations were approximately 50% of the Catapres maximum concentrations and occurred approximately 5 hours later relative to Catapres. Similar elimination half-lives were observed and total systemic bioavailability following KAPVAY was approximately 89% of that following Catapres.
Food had no effect on plasma concentrations, bioavailability, or elimination half-life.
Table 7 : Pharmacokinetic Parameters of Clonidine in Healthy Adult Volunteers
| Parameter | CATAPRES-Fasted n=15 | KAPVAY-Fed n=15 | KAPVAY-Fasted n=14 | |||
| Mean | SD | Mean | SD | MEAN | SD | |
| Cmax (pg/mL) | 443 | 59.6 | 235 | 34.7 | 258 | 33.3 |
| AUCinf (hr*pg/mL) | 7313 | 1812 | 6505 | 1728 | 6729 | 1650 |
| hTmax (hr) | 2.07 | 0.5 | 6.80 | 3.61 | 6.50 | 1.23 |
| T½ (hr) | 12.57 | 3.11 | 12.67 | 3.76 | 12.65 | 3.56 |
Figure 1 : Mean Clonidine Concentration-Time Profiles after Single Dose Administration
Multiple-dose Pharmacokinetics in Children and Adolescents
Plasma clonidine concentrations in children and adolescents (0.1 mg bid and 0.2 mg bid) with ADHD are greater than those of adults with hypertension with children and adolescents receiving higher doses on a mg/kg basis. Body weight normalized clearance (CL/F) in children and adolescents was higher than CL/F observed in adults with hypertension. Clonidine concentrations in plasma increased with increases in dose over the dose range of 0.2 to 0.4 mg/day.
Clonidine CL/F was independent of dose administered over the 0.2 to 0.4 mg/day dose range. Clonidine CL/F appeared to decrease slightly with increases in age over the range of 6 to 17 years, and females had a 23% lower CL/F than males. The incidence of “sedation-like” AEs (somnolence and fatigue) appeared to be independent of clonidine dose or concentration within the studied dose range in the titration study. Results from the add-on study showed that clonidine CL/F was 11% higher in patients who were receiving methylphenidate and 44% lower in those receiving amphetamine compared to subjects not on adjunctive therapy.
