Effective Use of Electroconvulsive Therapy in Late-Life Depression

Abstract

Objective: To review literature pertaining to the efficacy, safety, and tolerability of electroconvulsive therapy (ECT) in treating late-life depression. Method:We undertook a literature review with an emphasis on research studies published in the last 10 years.Results: There is a positive association between advancing age and ECT efficacy. Age per se does not necessarily increase the risk of cognitive side effects from ECT, but this risk is increased by age-associated neurological conditions such as Alzheimer's dementia and cerebrovascular disease. With appropriate evaluation and monitoring, ECT can be used safely in patients of very advanced age and in those with serious medical conditions. Several technical factors, including dose of electricity relative to a patient's seizure threshold, position of electrodes, frequency of administration, and total number of treatments, have an impact on the efficacy and cognitive side effects of ECT and need to be taken into account when administering ECT. Naturalistic studies have found that 50% or more of patients have a relapse of depression within 6 to 12 months of discontinuing acute ECT. Conclusions:In recent years, there has been substantial progress in our understanding of the effect of technical factors on the efficacy and cognitive side effects of ECT. When administered in an optimal manner, ECT is a safe, well-tolerated, and effective treatment in older patients. Relapse of depression after response to ECT remains a significant problem, and there is a need for further research into the prediction and prevention of post-ECT relapse. Clinical Implications · With appropriate evaluation and monitoring, electroconvulsive therapy (ECT) is a safe and effective treatment in elderly patients, including those of very advanced age and those with significant medical comorbidity. · Technical factors have a significant impact on the efficacy and side effects of ECT and need to be taken into account when administering the treatment. · Despite the use of continuation antidepressant medication, relapse of depression after ECT remains a significant problem. Limitations· Only 1 study, with a relatively small number of patients, has compared the efficacy and cognitive effects of high-dose right unilateral ECT with bilateral ECT. The findings of this study require replication in a larger group of patients recruited from more than 1 research centre. · The optimal electrical dose for right unilateral ECT remains to be established. · Data pertaining to the efficacy of continuation ECT are derived from uncontrolled or retrospective studies. However, data from the first controlled, prospective study of continuation ECT should soon be available.

Age-related cognitive effects of ECT and ECT-induced mood improvement in depressive patients

“…To our knowledge, this is the first time that treatment with index ECT of a geriatric patient group with medication-resistant depression shows cognitive improvement that lasts for at least 1 year [Flint and Gagnon, 2002;Tew et al, 1999;Wesson et al, 1997;Wilkinson et al, 1993;Zervas et al, 1993]. The results, although based on a relatively small number of subjects, thus indicate that older people given ECT for severe mood disorder do not suffer cognitive decline at long-term follow-up, but even show a benefit of ECT treatment.…”

“…The more recent study of Brodaty et al [2000] did include cognitive measures but did not provide details of ECT-techniques used. In a review, Flint and Gagnon [2002] concluded that ECT can be used safely in patients of very advanced age, with appropriate evaluation and monitoring, and administration in an optimal way. They suggest that the superior response to ECT among older compared with younger adults might not be related to aging per se but to age-related clinical factors, such as lengthier depressive episodes and more melancholic features in their mood.…”

“…They concluded that technical factors, such as electrical stimulation relative to convulsion threshold, electrode placement (uni-or bilateral), and frequency of treatment, may impair cognitive function and should be considered when balancing efficacy and speed of response with potential side effects. However, when administered in an optimal manner, ECT is considered a safe, welltolerated, and effective treatment in older patients [Flint and Gagnon, 2002].…”

“…Regarding positive effects on cognition, Wilkinson et al found that Mini-Mental State Examination (MMSE) scores recorded 72 h to 1 week after ECT course improved in all age groups, but magnitude of improvement was largest in older patients. In their review, Flint and Gagnon [2002] commented that this unexpected finding of improved cognition following ECT points to a complicated interaction between cognitive functions, changes in depression, and ECT administration.…”

Evidências da eficácia da eletroconvulsoterapia na prática psiquiátrica

“…In some reports, authors make references to situations in which there is an increasing risk with 5 the procedure, [40][41][42][43] such as intracranial lesions or conditions associated to an increase in the intracranial pressure, 40,43 history of cerebrovascular accident, 41,42 recent myocardial infarction with cardiac decompensation, severe systemic arterial hypertension (especially if it is associated with pheochromocytoma), presence of risk factors for intracranial hemorrhage and any condition associated to a 4 or 5 risk score of the American Society of Anestheologists (ASA). 18,44 It is also not contraindicated during pregnancy.…”