Electroconvulsive Therapy(ECT)

Indications for ECT(Electroconvulsive Therapy)

General Considerations

In contrast to its origins as a treatment of schizophrenia, ECT today is generally utilized more frequently in patients with depression, es-pecially psychotic depression and in the elderly. Mania and schizo-phrenia account for most of the remainder of convulsive therapy use. The indications have been most clearly spelled out by the American Psychiatric Association on ECT (American Psychiatric Associa-tion, 1990, 2001), which identified “primary ” and “secondary” use of convulsive therapy. Primary indications are those for which ECT may appropriately be used as a first-line treatment. These include situations where the patient’s medical or psychiatric condition re-quires rapid clinical response, where the risk of alternative treat-ments is excessive, or where, based on past history, response to ECT or nonresponse to medications is anticipated. If these conditions are not met, medication or other alternative treatment is recommended first, with ECT reserved for cases of nonresponse to adequate trial(s), unacceptable adverse effects of the alternative treatment, or deterio-ration of the patient’s condition, increasing the urgency of the need for response (American Psychiatric Association, 2001). These gen-eral principles in turn require individualized interpretation in the presence of specific psychiatric and medical disorders. Even where ECT is not used as treatment of first choice, its introduction sooner in the decision tree rather than being reserved as a “last resort” may spare the patient multiple unsuccessful medication trials, thereby avoiding months of suffering and possibly reducing the likelihood of treatment resistance (American Psychiatric Association, 2001). Modern diagnostic and clinical considerations in the recommenda-tion of ECT are summarized in Table 74.1.

ECT in Depression

It is well established that major depression is a heterogeneous dis-order, encompassing mildly ill, functioning outpatients, as well as profoundly disturbed, dysfunctional, or often psychotic inpatients. Along this spectrum, ECT appears higher in the treatment hier-archy for the more severe presenting depression, usually defined by the presence of neurovegetative signs, psychosis, or suicidality (Abrams, 1982; American Psychiatric Association, 2000, 2001).

While there are no absolute rules, severely melancholic or psychotically depressed patients are often appropriate candidates for ECT as treatment of first choice, whereas more moderately ill individuals might not be considered for ECT until adequate medication trials have failed.

Predictors of Response

The literature describes an overall response rate to ECT of 75 to 85% in depression (Crowe, 1984; O’Connor et al., 2001). Efforts to delineate subtypes of depression particularly responsive to ECT have yielded inconsistent results. ECT is most likely to be helpful in an acute episode of severe depression of relatively brief duration (Rich et al., 1984). Combined data from two simulated-ECT-controlled trials (Brandon et al., 1984; Buchan et al., 1992) identified the presence of delusions and psychomotor retardation as predictive of preferential response.

Psychotic depression, increasingly recognized as a distinct subtype of mood disorder that responds poorly to antidepressants alone, has emerged as a powerful indication for ECT (Potter et al., 1991; Petrides et al., 2001). In this subgroup, ECT is at least as effec-tive as a combination trial of antidepressant and antipsychotic med-ications. On balance, the evidence supports the early use of ECT in psychotic depression, particularly in lieu of prolonged, complicated medication trials that may be poorly tolerated, especially in the el-derly (Khan et al., 1987; Potter et al., 1991; Sackeim, 1993).

While bipolar (discussed below) and unipolar depressions are equally responsive to ECT (American Psychiatric Associa-tion, 2002), response may be less likely with secondary than primary depression, in both adults (Kramer, 1982; Zorumski et al., 1986; Zimmerman et al., 1986a), including the elderly

Bipolar Disorder

ECT is an extremely effective and rapidly acting treatment for both acute mania and bipolar depression (American Psychiatric Association, 2002). However, it is infrequently used for mania, because of the availability of pharmacological strategies. Nonetheless, ECT has been repeatedly endorsed as an accepted second- or third-line treatment for acute manic episodes, particularly in cases of medication resistance, in patients of all ages (NIH/NIMH, 1985; Goodwin and Jamison, 1990; Mukherjee et al., 1994; Van Gerpen et al., 1999; American Psychiatric Association, 2002). In medical emergencies associated with mania, ECT can be regarded as a treatment of first choice (American Psychiatric Association, 2002). The same is true for medical conditions accompanying acute mania (including pregnancy, discussed later) that contraindicate or render intolerable the use of psychotropic medications.

There is little information on which manic patients benefit most from ECT or on optimal ECT treatment in mania. Bipolar depression responds as well as unipolar depression to ECT, in both adult and geriatric patients (American Psychiatric Association, 2002). Hypomania or mania is a risk of using ECT for depression in bipolar patients, but this is not different from the experience with any antidepressant treatment in this disorder (Gormley et al., 1998; American Psychiatric Association, 2001, 2002).

Schizophrenia

Among the changes undergone by convulsive therapy over its 60-year history, few are as striking as those associated with its use in chronic psychotic illness. ECT has evolved from a treatment of first choice to often a treatment of last resort for DSM-IV schizo-phrenia. However, the efficacy of ECT for depressive symptoms associated with psychotic illness is reflected in recent nationwide data showing the use of convulsive therapy in almost 12% of patients with recurrent major depression comorbid with schizo-phrenia (Olfson et al., 1998), a utilization rate higher than that seen in uncomplicated recurrent depressive disorder.

The American Psychiatric Association Task Force on ECT (American Psychiatric Association, 2001) and the Canadian Psy-chiatric Association (Enns and Reiss, 1992) identified a role for ECT as a second-line treatment for selected patients with schizo-phrenia, particularly when associated with a brief duration of ill-ness and/or affective symptoms.

It has been consistently found that the schizophrenic patients most likely to respond to ECT are those with good prognosis signs: mood disturbances, short duration of illness, predominance of positive rather than negative symptoms, and overexcitement (Fink and Sackeim, 1996). The potential respon-siveness of acute psychotic symptoms in schizophrenia to ECT is more emphatically stated in the 2001 revision of the American Psychiatric Association Task Force Report compared with the previous edition, based on research conducted and compiled in the intervening decade (Fink and Sackeim, 1996).

Other Axis I Disorders

As reiterated in the Surgeon General’s report on mental health (US Department of Health and Human Services, 1999), ECT has no demonstrated efficacy in dysthymia, substance abuse, or anxi-ety disorder. Nonetheless, ECT may play a role when the sever-ity of a secondary major depression is severe and/or treatment refractory (American Psychiatric Association, 2001). In such cir-cumstances, ECT can be expected to improve the comorbid mood component, leaving the underlying primary disorder untreated; in some circumstances, removal of the burden of overlying de-pression may indirectly benefit the underlying disorder. In the face of a potentially ECT-responsive major depressive episode, the presence of a nonmood Axis I disorder, even substance abuse, should not constitute a contraindication to the use of convulsive therapy (Olfson et al., 1998; American Psychiatric Association, 2001).

Axis II Disorders

There are no evidence-based biological treatments for DSM-IV Axis II personality disorders, including ECT. Given the high incidence of comorbid, often treatment-refractory depression that accompanies Axis II pathology, ECT has been used in per-sonality disordered patients, with inconsistent – but generally negative – reports of success, for many years.

Neurologic Disorders

Only 1% of patients admitted with a primary diagnosis other than a mood disorder or schizophrenia are treated with ECT in this country (Thompson et al., 1994). Nonetheless, individuals with neurologic or other medical problems often suffer from primary or secondary mood or motor disorders that are ECT-responsive.

Catatonia

Over the past decade, benzodiazepines have emerged as the phar-macological treatment of choice for catatonia (Rosebush et al., 1992; Ungavari et al., 1994). However, in medication-unrespon-sive patients, prolonged drug trials with continuing clinical de-terioration can be avoided in favor of a course of ECT (Ungavari et al., 1994). Reflecting current understanding of the syndrome and its treatment, Fricchione (1989) recommended that “given the significant morbidity and mortality associated with catatonia, ECT should be considered if an expeditious 48- to 72-hour ben-zodiazepine trial is unsuccessful”. As a practical point, given the now-common initial use of benzodiazepines in this condition, the catatonic patient may come to ECT with an initially elevated seizure threshold, and treatment parameters should be adjusted accordingly (Fink, 2002).

Other Neurologic Illness

The remaining neurological indications for ECT can be consid-ered to fall into two major categories: 1) those for which, as with any medical illness, ECT is considered for treatment of a sec-ondary depression when benefit–risk analysis favors ECT over antidepressant medications and 2) those for which ECT may play a special role by virtue of its unique actions compared with alter-native treatment options.

In the first category are such conditions as poststroke depression (Murray et al., 1986; Currier et al., 1992) and mood disturbance in the context of brain trauma, tumor, or dementia (Hsiao et al., 1987; Liang et al., 1988; Kohler and Burock, 2001). Medication may be difficult to tolerate by these neurologically ill patients, tilting the potential benefit–risk ratio in favor of ECT (Price and McAllister, 1989).

Potential contraindications to ECT are very few and rarely are absolute (American Psychiatric Association, 2001). Although ECT generally should not be performed in the pres-ence of raised intracranial pressure, it has been given safely even in the face of brain tumors and other mass lesions (Hsiao et al., 1987; Fried and Mann, 1988; Abrams, 1991; Kohler and Burock, 2001) with special steps taken to protect against the ECT-associated hemodynamic changes; intracranial pres-sure may be reduced with the use of oral or parenteral steroids (Beale et al., 1997).

Other Considerations in the Use of ECT

It can be appreciated that while accurate psychiatric diagno-sis is essential to prioritize treatment options, it is far from the only consideration for the clinician weighing the advantages and potential problems of prescribing ECT (American Psychiatric Association, 2001). Two often-related variables are the patient’s state of physical health and age. A large number of individuals receiving ECT in this country are elderly, many of whom are physically compromised.

Two general points should be made about the use of ECT in the elderly: 1) the physiological changes associated with ECT – cardiovascular (elevated blood pressure, arrhythmias), cognitive (confusion, memory loss), risk of traumatic injury to bones and teeth – that are benign and easily tolerated in young and middle-aged patients are prominent sources of potential ECT-associated morbidity in geriatric patients, and 2) the safety of ECT is appreciably enhanced if the foregoing effects on the older body, whether healthy or diseased, are anticipated and con-trolled. For example, Casey and Davis (1996) noted that a “rigor-ous falls prevention protocol” helped protect their elderly ECT patients from a potentially dangerous complication seen in ear-lier studies

The very limited use of modern ECT in young people is generally reserved for cases of depression or mania complicated by medication resistance or the need for an urgent clinical re-sponse. Nonetheless, where ECT is utilized in younger patients, its efficacy and safety appear comparable to those in adults (Rey and Walter, 1997; Cohen et al., 2000).

A special physical health challenge to the treatment of mental disorders is presented by pregnancy. Guidelines for the administration of ECT in the pregnant patient, incorporating measures such as intravenous hydration, avoidance of hyperven-tilation and nonessential anticholinergic medication, measures against gastric reflux, proper positioning of the patient during treatment, and uterine and fetal cardiac monitoring, have been developed and incorporated into modern practice (American Psychiatric Association, 2001).

Pretreatment Evaluation

Once the decision has been made to proceed with a course of ECT, specific steps are taken by the treatment team to maximize the benefits and minimize the risks. In some instances these pro-cedures are part of the initial work-up, and the results may influ-ence treatment decisions, as when certain psychiatric or physical disorders are ruled in or out.

The psychiatrist will want to make use of appropriate consultants, especially representing the fields of anesthesiol-ogy and, when indicated, internal medicine (often cardiology) or obstetrics. Given the current regulatory climate, the physician needs to be aware of local requirements regarding the need for second opinions or other pretreatment procedures in certain cir-cumstances, or to arrange for guardianship or court proceedings where the patient’s capacity to consent to ECT is in question, to assure that the initiation of treatment is not unduly delayed.

Psychiatric Considerations

The pre-ECT evaluation is a good time to confirm psychiatric diagnosis, including Axis II and III. In many settings, a specific ECT consultation may be helpful in evaluating the patient for a potentially ECT-responsive disorder and weighing the various treatment options (Klapheke, 1997). Input from nursing and other professional staff that have been working with the patient should be factored in. Should the indications for ECT remain present, baseline assessments of mental status including evaluation of suicidality, orientation and memory will help monitor changes in both therapeutic and adverse effects over the course of treatment. The history and effects of previous treatment with ECT should be obtained. Also, this time, decisions must be made regarding ongoing psychotropic medications particularly those increasing the risk of toxicity in combination with ECT, for example lithium and those affecting seizure threshold, such as benzodiazepines and anticonvulsants – and steps instituted to adjust, taper, or dis-continue these medications, when appropriate.

Other Medical Considerations

History and physical examination should focus on the cardiovas-cular and neurological systems, the areas of greatest risk. The consulting internist, anesthesiologist, or other physician should advise the treatment team regarding cardiovascular risk of ECT and the need for any modifications in treatment technique, such as medications to moderate hemodynamic changes (Dolinski and Zvara, 1997). Appropriate pretreatment optimization and moni toring of medical conditions that may be affected by ECT, such as diabetes, should be arranged at this time.

In the uncomplicated situation, the routine laboratory work-up for ECT is that indicated for any procedure involving general anesthesia: complete blood count, serum electrolyte levels  and  electrocardiogram  (ECG)  (American  Psychiatric Association, 2001; Chaturvedi et al., 2001). Chest X-ray is often obtained as well. The need for further pretreatment work-up, such as serum chemistries, urinalysis, HIV antibody titers and medication blood concentrations, is determined on an individual basis (Lafferty et al., 2001). Given a normal neurologic and fundoscopic examination, computerized tomography (CT) or magnetic resonance imaging (MRI) of the brain is not indicated.

Lumbosacral spine films, historically routine prior to institution of muscle relaxation in the ECT premedication protocol, have become optional for many patients. This remains appropriate for older patients with a history of or at risk for osteoporosis, and for any patient with a history of bone trauma. A formal anesthesiology consultation should result in an assignment of the degree of anesthesia risk and recommendations for any necessary modification in the ECT protocol (Folk et al., 2000). A personal or family history of anesthesia complications may call for special assessment. The condition of dentition should be routinely assessed to avoid the treatment-associated risk of aspiration or fracture of loose teeth or bridgework.

Informed Consent

Among the unique features of ECT compared with other standard psychiatric treatments is the requirement for written informed consent by the patient or legal guardian or other substitute. Guidelines regarding the content of a standard informed consent form for ECT have been published (American Psychiatric Asso-ciation, 2001). Supplemental information regarding ECT for pa-tients and their families in a variety of media is also available and its distribution is encouraged (Fink, 1999; American Psychiatric Association, 2001).

The NIH/NIMH Consensus Development Conference on ECT (1985) emphasized that informed consent is a process that continues throughout the treatment course. Given the transient cognitive impairments common in depression and during an ECT course, it is particularly necessary to maintain a dialogue with the patient as treatment progresses to assure that all of the patient’s questions and concerns are addressed, even if repetitive discourse ensues. With appropriate modification of the presenta-tion of information, including use of nonverbal demonstration of the procedure, even patients with mental retardation often can make informed decisions about consent for ECT (Van Waarde et al., 2001).