Refinements in ECT Techniques

Electroconvulsive therapy (ECT) has been practiced since 1938 and is one of the best-studied treatment modalities. Because of its long history‚ it has been the comparator for a number of subsequent therapies‚ including pharmacological and other somatic interventions. Even with ECT‚ however‚ the response rate for treatment-refractory patients is sobering‚ and the treatment is not without risks and adverse effects.¹ Still‚ it can be effective when other interventions have failed.

Treatment-refractory major depression is the primary indication for ECT‚ although ECT may have particular utility in psychotic depression‚ catatonia‚ and suicidality as well.2 The American Psychiatric Association (APA) guidelines also list an indication for schizophrenia.³

The Case Vignette illustrates a fairly typical case for ECT referral‚ and the patient is a reasonable candidate.

CASE VIGNETTE

John‚ 55 years old‚ is referred for ECT evaluation. He has a long history of recurrent major depression (including in childhood)‚ with onset of the current episode 6 months earlier. He presents with depressed mood‚ anxiety‚ middle insomnia‚ social isolation‚ marked fatigue‚ significant anhedonia‚ and profound loss of interest and motivation. His concentration‚ attention‚ and short-term memory are also negatively affected. His appetite is normal and his weight is stable. He denies suicidal ideation and past suicide attempts but acknowledges thinking that his life is pointless. He denies psychotic or manic symptoms. He is having problems at work and there is significant marital discord at home.

John first sought treatment in his early 30s. He has taken a number of antidepressants of different classes‚ some of which worked partially‚ until they lost their effectiveness or he had unacceptable adverse effects. He desperately wants symptom relief‚ as soon as possible‚ but is very concerned about cognitive adverse effects of ECT.

To suppress the electrically induced tonic-clonic motor seizure activity‚ and thus minimize musculoskeletal complications‚ paralytic agents are administered. Because conscious paralysis would be very distressful‚ patients receive general anesthesia. ECT entails a series of treatments‚ typically 6 to 12‚ to achieve response or remission. Cognitive adverse effects are the major concern‚ especially for patients and their families.^4‚5 Even with full remission‚ relapse rates remain high‚ particularly for the nonpsychotic medication–resistant population.¹ Generally‚ once symptom remission is achieved‚ ECT is frequently discontinued. However‚ some patients get continuation (to prevent relapse) or maintenance (recurrence prophylaxis) ECT.^3‚6‚7

When to refer

The decision to pursue ECT is based on a number of factors‚ including “ diagnosis‚ type and severity of symptoms‚ treatment history‚ consideration of the anticipated risks and benefits of ECT and alternative treatment options‚ and patient preference.”3 The principal diagnostic indication is unipolar or bipolar depression. “ Policies and procedures should be developed to ensure proper informed consent‚ including when‚ how‚ and from whom consent is to be obtained and the nature and scope of information to be provided. . . . Informed consent should be obtained from the patient except when the patient lacks capacity to consent.”³

There is evidence to suggest that a significant number of patients referred for ECT have not had adequate medication trials.^6‚8‚9 The response rate for patients who are not medication-resistant is higher‚ up to 90% in one multisite study (log-linear analysis x2 = 6.82‚ df = 1‚ P = .009)‚ with site differences in the rates of patients classified as medication-resistant‚ patient age‚ Hamilton depression scores‚ and total number of ECT sessions.

The global rating of reliability did not differ among patients who were classified as medication-resistant and having inadequate pharmacotherapy before ECT.⁸ The FDA efficacy review estimated the overall treatment effect to be 78%.10 For treatment-refractory patients‚ the ECT response rate may be about 50% to 60%.^8‚9

Personality disorders comorbid with major depression are common‚ with poorer outcomes with psychotherapy or pharmacotherapy. Patients with these comorbid conditions are likely to be referred for ECT. One study examined 139 patients with a primary diagnosis of unipolar major depression and scores of at least 20 on the 24-item Hamilton Depression Rating Scale; personality disorders were assessed with a structured interview. Outcomes were compared in patients with no personality disorder‚ patients with borderline personality disorder‚ and patients with personality disorders other than borderline personality disorder. Only 22% of patients with borderline personality disorder met criteria for remission‚ compared with 56% of patients with personality disorders other than borderline personality disorder and 70% of patients with no personality disorder.

Findings from the study indicate that the diagnosis of borderline person­ality disorder is a predictor of poor response to ECT (x2 = 11.63‚ df = 1‚ P = .001) and has potentially significant implications for the selection of candidates for ECT.¹¹ Still‚ the APA guidelines do not suggest a prohibition of ECT in patients with comorbid borderline personality disorder. There is a similar stance for patients with comorbid dysthymia‚ because ECT is rarely used for dysthymia alone.³

ECT can be rapidly effective in mania and catatonia‚ and it can be an early consideration for depressions with psychotic features. Although antipsychotics continue to be the first-line intervention‚ ECT can be considered in patients with medication-resistant schizophrenia. However‚ the probability of significant improvement may be low. There are special considerations for children and adolescents (additional evaluation from a child and adolescent psychiatrist is recommended) and for pregnant women (procedural considerations and additional monitoring are needed).³

Contraindications

Unfortunately‚ some practitioners see ECT as a treatment of last resort‚ whatever the presenting diagnosis. This kind of thinking on the part of referring psychiatrists and patients is discouraged. There are relative contraindications for ECT‚ but few absolute ones. Many patients present with comorbid psychiatric disorders for which ECT is not indicated. There are comorbid medical conditions that also affect the risk to benefit ratio.

Electrically induced seizures can be associated with transient cardiovascular changes (asytole‚ bradycardia‚ tachycardia‚ hypertension‚ increased myocardial oxygen demand)‚ increased intracranial pressure‚ increased intraocular pressure‚ release of catecholamines‚ and other effects that can exacerbate preexisting conditions. These conditions require optimization of their management and/or procedural changes to minimize morbidity and mortality.

Precautions must be taken in patients with unstable or severe cardiovascular conditions (eg‚ recent myocardial infarction‚ unstable angina‚ con­gestive heart failure‚ uncontrolled hypertension)‚ aneurysm‚ increased intracranial pressure‚ recent cerebral infarction‚ or pulmonary conditions (eg‚ chronic obstructive pulmonary disease‚ asthma‚ pneumonia)‚ and in patients who fall into the American Society of Anesthesiologists rating level 4 or 5.3

The mortality rate has fallen over the decades of ECT practice.12 The number of deaths resulting from ECT is estimated to be 1 per 10‚000 patients‚ or 1 per 80‚000 treatments.³ The Veterans Affairs (VA) National Center for Patient Safety database estimate is less than 1 death per 73‚400 treatments (or less than 1 per 14‚000 patients). No associated deaths were reported in any VA hospital between 1999 and 2010.¹³ In California from 1984 to 1994 and in Texas from 1993 to 1998‚ there were less than 2 deaths per 100‚000 treatments.^14‚15

TECHNIQUE

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