Electroconvulsive Therapy
Walter Knysz III
Edward C. Coffey
The use of convulsive therapies in the treatment of major mental illness dates back to the use of camphor in the 16th century.1 The use of electricity to induce a therapeutic seizure first occurred in 1938 and provided the benefit of being shorter acting and more reliable.1,2 Electroconvulsive therapy (ECT) was first used in the United States in 1940, with many technical advances since that time.1, 2, 3, 4 ECT has a strong safety record and in some patients is better tolerated than psychotropic medication.1, 2, 3 The efficacy of ECT for specific disorders has been well established in the medical literature, and ECT may work more rapidly than alternate forms of treatment.1, 2, 3, 4, 5, 6 When used to treat an acute episode of a mood disorder, ECT may be started on either an inpatient or outpatient basis (the grounds for this decision are discussed in subsequent text), and when used to protect against relapse/recurrence it is typically performed as an outpatient procedure.2,4 Like many other treatments in medicine, the exact reasons for the effectiveness of ECT are uncertain.1,4 It is known, however, that the benefits of ECT depend on producing a seizure and that technical factors related to how the seizure is produced are also important.1, 2, 3, 4 Research continues in attempts to understand better the biochemical processes responsible for the efficacy of ECT and to refine further the technical aspects of the procedure.
Indications
ECT is most often considered when patients do not respond to adequate medication trials, a situation commonly encountered on an inpatient psychiatric unit. Other reasons include a lack of tolerance to medication side effects, prior response to ECT, patient preference, and clinical circumstances that require rapid response for medical and/or psychiatric reasons. These situations include, but are not limited to, clinical deterioration, suicidality, and catatonia, all of which are also commonly seen on an inpatient psychiatric unit.1, 2, 3, 4, 5, 6
A substantial body of literature documents the efficacy of ECT in the treatment of mood disorders.1, 2, 3, 4, 5, 6 This includes the treatment of unipolar depression (single and recurrent), bipolar depression, mania, and mixed states. Treating a patient with bipolar disorder depression with ECT may produce a “manic switch.” In such cases, treatment would continue in a similar manner, as ECT can be effective in treating both bipolar depression and mania.
ECT can also be effective in treating psychotic disorders such as schizoaffective disorder, schizophreniform disorder, and schizophrenia.2,7, 8, 9, 10 Particular consideration should be given to ECT in the setting of catatonia, when a psychotic episode develops over a short period of time, and when a patient has successfully responded to ECT in the past.1, 2, 3, 4, 5, 6,11,12
In addition to the primary psychiatric disorders listed in the preceding text, ECT may also be efficacious in the treatment of patients with serious affective and psychotic symptoms due to medical conditions, although the data to support this indication are less clear. There is also some suggestion that ECT may be effective in treating some medical conditions such as Parkinson disease, intractable seizures, and delirium.1, 2, 3, 4, 5, 6,13, 14, 15, 16, 17, 18, 19, 20
Of particular relevance in an inpatient setting, ECT can be effective in treating neuroleptic malignant syndrome (NMS) as well as catatonia (regardless of the etiology).21, 22, 23, 24, 25, 26 However, before treating a
patient with NMS with ECT the vital signs should be stabilized. As the offending antipsychotic agent is discontinued in patients having NMS, and rechallenging them with an antipsychotic at a later point in time is not without risk, ECT has the added benefit of potentially being effective in the treatment of the underlying psychiatric disorder as well as treating the NMS.1, 2, 3, 4, 5, 6
patient with NMS with ECT the vital signs should be stabilized. As the offending antipsychotic agent is discontinued in patients having NMS, and rechallenging them with an antipsychotic at a later point in time is not without risk, ECT has the added benefit of potentially being effective in the treatment of the underlying psychiatric disorder as well as treating the NMS.1, 2, 3, 4, 5, 6
Pre-Electroconvulsive Therapy Evaluation
The pre-ECT evaluation consists of several components, including a neuropsychiatric and medical evaluation performed by a clinician experienced in ECT, a general medical evaluation performed by an anesthesiologist, initiation of the informed consent process, and preparation of the patient and family for the treatment. The goal of the neuropsychiatric evaluation is to determine the indication for ECT; establish a baseline for outcome measures including a baseline of cognitive functioning; and screen for, identify, and develop a plan to manage any medical conditions that would increase the risk of the procedure. These goals are accomplished by taking a thorough medical and neuropsychiatric history, including an interview and review of available records, and performing a thorough neuropsychiatric examination.1, 2, 3, 4, 5, 6
A thorough psychiatric evaluation should identify whether an indication for ECT is present. This includes a diagnostic evaluation as well as review of previous medication trials (including dose, duration, efficacy, and side effects), response to previous courses of ECT, and identification of a need for rapid and definitive response to treatment.1, 2, 3, 4, 5, 6
The identification of outcome measures and the collection of objective data at baseline as well as periodically during the treatment course are essential. This is true of psychiatric symptoms and functioning as well as of cognitive functioning.1, 2, 3, 4, 5, 6 The APA Task Force Report (2001) summarizes the use of a number of standardized rating scales that may be utilized in addition to the clinical interview.2 Assessment tools used in physicians’ practice include the Montgomery-Asberg Depression Rating Scale (MADRS), the Bech and Rafaelsen Mania Rating Scale, the Carroll Self-Rating Scale for Depression, the Global Assessment of Functioning (GAF) scale, the Social and Occupational Functioning Assessment (SOFA) scale, and the Karnofsky scale. The present authors also use the Mini Mental State Examination (MMSE) to track cognitive status during a treatment course. Additionally, the present authors administer the CogniStat before and at the conclusion of an index course as it may provide further detail about a patient’s cognitive status and is relatively easy to administer. Further clinical perspective may be gained from interviewing family or friends over the course of treatment.6
Screening for medical risk factors cannot be overemphasized. Although ECT is generally a very safe procedure, the risk of morbidity and mortality increases in the context of comorbid medical risk factors. Appropriate management of these medical risk factors is essential to minimizing this risk. This is especially true in an inpatient setting as these patients are likely to have more severe medical and psychiatric problems. When screening for risk factors, the clinician should pay special attention to the neurologic and cardiopulmonary systems, as ECT produces transient but significant changes in cerebral and cardiovascular physiology. A patient with a history of significant cardiac disease, such as ischemia or heart failure, requires careful evaluation. Stabilization of these conditions is required before proceeding with treatment, and the treatment technique may need to be modified. A thorough neurologic examination should also be performed. If any abnormalities are discovered, further evaluation including neuroimaging may be required. A patient with a history of significant skeletal disease may require x-rays of the spine and a patient with significant pulmonary disease likely requires a chest x-ray. A patient’s dentition should also be examined and note taken of any loose or chipped teeth and the presence of dentures.1, 2, 3, 4, 5, 6, 7
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