ECT remains a standard treatment in modern psychiatric medicine for a range of severe psychiatric illnesses because of its unmatched efficacy and speed of response. Recent changes in psychiatric nosology and practice clarify the role of ECT for catatonia and melancholia—2 syndromes for which ECT is a most effective and often lifesaving treatment. For these syndromes, optimally administered ECT typically provides relief within 1 to 3 weeks.
Catatonic patients, especially those with febrile malignant catatonia or the neuroleptic malignant syndrome and those who refuse feeding, should be treated without delay. Unfortunately, antidepressant medications are prescribed for many melancholic patients—often multiple trials of up to 6 weeks each—before ECT is recommended. More severely depressed patients, who are agitated, suicidal, and losing weight, should be referred for ECT as a primary treatment.
Indeed, the remarkable, well-replicated efficacy of ECT for these 2 syndromes raises questions about accepted treatment algorithms that call for 2 or more medication trials, often with multiple medications combined with psychotherapy. Many clinicians question the ethics of such treatment algorithms that ask patients to suffer weeks, even months, of trials before the effective treatment of ECT is prescribed. For both ethical and economic reasons, when patients are acutely ill with catatonia and melancholia, ECT is best considered sooner rather than later.
A century ago, following the images created by Emil Kraepelin, catatonia was seen as a marker of schizophrenia and classified as one of its recognized types. By the 1990s, DSM-IV recognized catatonia as secondary to a medical condition; in the latest iteration, DSM-5 discarded the class of catatonia as a type of schizophrenia and retained it mainly as a systemic medical condition. Much has been learned.
Catatonia rating scales identify more than 20 motor behaviors, including posturing, rigidity, staring, mutism, and repetitive thoughts and acts that mark the stuporous form. Two or more signs that last for 24 hours suggest the presence of the syndrome. The diagnosis can be verified by rapid relief, a 50% reduction in the rating scale scores, with the intravenous administration of 1 to 2 mg of lorazepam. Catatonia is first treated with increasing doses of a benzodiazepine; for lorazepam, often up to 30 mg/d. Up to 80% of patients respond to high-dose lorazepam treatment.1
For those who do not respond or for those with a malignant form of catatonia—with fever, autonomic dysfunction, and stupor—ECT is the primary treatment. ECT can be optimized in several ways. For febrile patients, daily treatment may be necessary.
Dr. Kellner is Chief of Electroconvulsive Therapy, New York Community Hospital, Brooklyn, NY. Dr. Fink is Professor Emeritus, Departments of Psychiatry and Neurology, Stony Brook University, Stony Brook, NY.
1. Sienaert P, Dhossche DM, Vancampfort D, et al. A clinical review of the treatment of catatonia. Front Psychiatry. 2014;5:181.
2. Albala AA, Greden JF, Tarika J, Carroll BJ. Changes in serial dexamethasone suppression tests among unipolar depressive receiving electroconvulsive treatment. Biol Psychiatry. 1981;16:551-560.
3. Kellner CH, Husain MM, Knapp RG, et al. A novel strategy for continuation ECT in geriatric depression: phase 2 of the PRIDE study. Am J Psychiatry. 2016;173:1110-1118.
4. Slade EP, Jahn DR, Regenold WT, Case BG. Association of electroconvulsive therapy with psychiatric readmissions in US hospitals. JAMA Psychiatry. June 28, 2017; Epub ahead of print.
5. Sackeim HA. Modern electroconvulsive therapy: vastly improved yet greatly underused. JAMA Psychiatry. June 28, 2017; Epub ahead of print.
Fink M, Kellner CH, McCall WV. Optimizing ECT technique in treating catatonia. J ECT. 2016;32:149-150.
Krystal AD, Watts BV, Weiner RD, et al. The use of flumazenil in the anxious and benzodiazepine-dependent ECT patient. J ECT. 1998;14:5-14.
Luchini F, Medda P, Mariani MG, et al. Electroconvulsive therapy in catatonic patients: efficacy and predictors of response. World J Psychiatry. 2015;5:182-192.