When to consider electroconvulsive therapy (ECT)

Abstract

When to consider electroconvulsive therapy (ECT) Kellner CH, Obbels J, Sienaert P. When to consider electroconvulsive therapy (ECT).Objective: To familiarize the reader with the role of electroconvulsive therapy (ECT) in current psychiatric medicine. Method: We review clinical indications for ECT, patient selection, contemporary ECT practice, maintenance treatment and ECT in major treatment guidelines. Results: ECT is underutilized largely due to persisting stigma and lack of knowledge about modern ECT technique. Conclusion: ECT remains a vital treatment for patients with severe mood disorders, psychotic illness and catatonia. Clinical recommendations for ECT• ECT should be prescribed earlier in the course of a severe depressive episode, not necessarily withheld until after numerous medication trials • ECT may be considered a first-line (primary) treatment for certain urgently ill patients, including those who are very suicidal, psychotic, or physically debilitated from depression Diagnostic indications for ECT • In many Western countries, severe and treatment-resistant depression is the main indication for ECT • Schizophrenia is the number one indication for ECT worldwide, but is little used for this indication in Western countries • ECT is an effective treatment for treatment-resistant mania • Delirious mania is an urgent indication for ECT • ECT is effective for treatment-resistant schizophrenia, including clozapine-resistant illness • Catatonia is very responsive to ECT • Both the motor and behavioural symptoms of Parkinson's disease respond to ECT Predictors of ECT response • Older age, psychotic symptoms, and shorter episode duration are predictors of better ECT response • Melancholic features and greater baseline depressive symptom severity are likely associated with better ECT response 304 ECT technique • Bilateral, bifrontal, and right unilateral electrode placement are all effective ECT techniques • Less urgently ill patients are often treated initially with right unilateral electrode placement • Brief and ultrabrief pulse width stimuli, now commonly used, are associated with a more benign cognitive effect profile • There is no a priori fixed number of ECT in an acute course: patients should continue treatment with ECT until they remit or a plateau has been reached, or tolerability issues require interruption of the course • Tapering of acute courses of ECT should be considered for most patients (e.g., approximately weekly treatments for several weeks past remission) • Continuation/Maintenance (C/M) ECT should be considered for patients with a history of severe, recurrent episodes who have failed to remain well on medications Additional comments • ECT is underutilized because of stigma, lack of knowledge about it, and bureaucratic restrictions • ECT is among the safest procedures performed under general anesthesia • Cognitive adverse effects are markedly decreased with modern ECT techniques, largely transient, and should not deter seriously ill patients from considering ECT.

Understanding electroconvulsive therapy‐related anxiety: a prospective study

“…Despite the knowledge that electroconvulsive therapy (ECT) is highly effective in the treatment of major depressive episodes (1) and that ECT is safe and well tolerated, it is still plagued by stigma and negative perceptions (2)(3)(4). A significant proportion of patients experience anxiety for ECT (5,6), often to such an extent that it negatively impacts treatment compliance (5,7,8).…”

Electroconvulsive therapy (ECT) – brief history and guidelines

“…Nowadays brief and ultrabrief pulse width stimuli are commonly used, what is associated with a more benign cognitive effect profile. [5] The treatment is monitored using equipment that allows to assess its effectiveness. It takes about 15 minutes to awaken the patient from the moment of anesthesia to awakening, then vital signs are monitored for about half an hour -ECG recording, blood pressure, heart rate, and oxygen saturation of the blood.…”

“…[3] There is no a priori fixed number of ECT in an acute course: patients should continue treatment with ECT until they remit or a plateau has been reached, or tolerability issues require interruption of the course. [5] Usually, a series of treatments consists of 8 to 15 treatments performed 2-3 times a week. In some patients, further treatments are considered to maintain the achieved improvement.…”

“…Older age, psychotic symptoms, and shorter episode duration as well as melancholic features and greater baseline depressive symptom severity are predictors of better ECT response. [5] The decision to refer the patient to electroconvulsive treatment is made by a psychiatrist, after analyzing the current course of the disease, the current mental and somatic condition and obtaining the patient's consent. The commencement of treatments is preceded by a qualification procedure consisting in carrying out appropriate examinations and medical consultations.…”

Blues in the Brain and Beyond: Molecular Bases of Major Depressive Disorder and Relative Pharmacological and Non-Pharmacological Treatments

“…A relevant issue concerning non-pharmacological treatments is that this term refers to a myriad of procedures that have in common the non-use of drugs, but which are strongly different one to each other. To date, the non-pharmacological treatments widespread in clinical practice for the treatment of MDD (particularly for severe and recurrent forms) that have demonstrated strong efficacy and have been reported in the National Institute for Health and Care Excellence guidelines update in 2019 are ECT, repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS) among neuromodulation strategies, and CBT and interpersonal psychotherapy (IPT) among psychotherapies [11][12][13][14].…”