Electroconvulsive Therapy (ECT) David G. Wilkinson

INDICATIONS Depressive Disorders

The introduction of ECT for the treatment of severe depressive illness is one of the most dramatic developments in psychiatry. It is widely considered to be the most effective treatment for severe depressive illness compared with all other modalities including the range of pharmacological treatments. Since its introduction in the early 1930s it has undergone important development and improvement with the use of anaesthesia and muscle relaxation which rendered it more safe and acceptable. The recall of ECT in the USA in the 1970s was ‘plagued by hostility to the treatment’¹⁷ fuelled by images of barbaric, inhumane and coercive treatment. In contrast to such an approach, many national psychiatric associations and societies have promoted ECT and many countries have introduced guidelines for practice: Australia, Canada, New Zealand, UK and the USA¹⁸. It is, however, of considerable concern that in many third-world countries, ECT is still used without the benefit and safety of anaesthesia or modern ECT devices¹⁷‘¹⁹.

The Evidence Base

A recent systematic review and meta-analysis of randomized controlled trials and observational studies of the efficacy and safety of ECT in depressive disorders²⁰ reported the following findings:

ECT versus simulated ECT – ECT was significantly more effective than simulated ECT in the reduction of depressive symptoms and no difference in premature discontinuation from treatment for patients receiving ECT and simulated ECT. Patients treated with ECT were better able to retrieve remote memories than those treated with simulated ECT and had more recognition errors immediately after treatment.
ECT versus pharmacotherapy – treatment with ECT was significantly more effective than pharmacotherapy and discontinuation was significantly lower in the ECT group than in the pharmacother- apy group.
Bilateral versus unilateral electrode placement – Bilateral ECT was more effective than unilateral ECT in the reduction of depressive symptoms. High-dose unilateral ECT might be as effective as bilateral ECT and causes fewer adverse cognitive effects. Bilateral ECT was associated with impairment in anterograde memory impairment within seven days of the end of the randomized phase of treatment but no long-term cognitive impairment.
Frequency of ECT – ECT administered once a week, twice and three times a week had similar effects on depressive symptoms and no difference in discontinuation of treatment but more frequent ECT led to more cognitive impairment.
Dose of electrical stimulus – high-dose ECT led to greater reduction in depressive symptoms, but was associated with more impairment in anterograde memory but not in terms of personal memory.
Stimulus wave form – brief pulse and sine wave ECT were equally effective with some indication that patients receiving brief pulse ECT recovered more quickly and had better recall of word associates learned shortly before the treatment than did those receiving sign wave ECT.

A meta-analysis of the efficacy of ECT in depression deriving from 15 randomized controlled trials (RCTs) showed ECT to be superior to pharmacotherapy and simulated ECT, with the presence of psychotic symptoms predicting better response to ECT²¹. The report found no evidence for a superior speed of action of ECT or for a difference between sine wave and brief pulse stimulation. ECT has been shown to be more effective in delusional than in non-delusional depression^22,23. A recent Cochrane Review assessed the efficacy and safety of ECT compared to simulated ECT or antidepressants in the depressed elderly²⁴. Only three trials could be included and all had methodological shortcomings. The results nonetheless indicated that ECT was more effective than simulated ECT, but the comparative efficacy of unilateral over bilateral ECT and safety could not be assessed adequately.

Older age confers a greater likelihood of achieving a remission with bilateral, dose-titrated, continuation ECT in comparison with continuation pharmacotherapy²⁵.

The NICE Review²⁶ of data from 90 randomized controlled trials (RCTs) of ECT in depressive disorders (not specifically in older people) concluded that:

real ECT (where electric current was applied) is more effective than simulated ECT (no electric current was applied) in the short term;
bilateral ECT is more effective than unilateral ECT;
raising the electrical stimulus above the individual’s threshold supported the efficacy of unilateral ECT at the expense of increased cognitive impairment.
ECT was more effective than antidepressants notwithstanding the variable quality of RCTs and the inadequate doses and duration of antidepressants that were used in many of the trials;
ECT is associated with cognitive impairment, particularly in those who had bilateral ECT or unilateral ECT applied to the dominant hemisphere;
cognitive function does not last more than six months from the administration of ECT;
there is no evidence that ECT is associated with greater mortality than that associated with the administration of general anaesthetics. Studies that use brain-scanning techniques showed no evidence that ECT causes brain damage;
there is no evidence to suggest that the benefits and safety of ECT are age-dependent;
there are no complications of ECT in pregnancy but the risks should be balanced against refusing antidepressant.

As mentioned studies on the efficacy of ECT, which have largely been conducted on younger patients⁸, all emphasize that ECT appears to be more effective than placebo, single-drug therapy and tricyclic/neuroleptic combinations, and that patients with more florid symptoms of recent onset fare best^27-29. Experience with the elderly would confirm these findings. Indicators of response are perhaps less clear in the elderly, with some authors finding psychomotor disturbance and psychosis a positive predictor of response¹¹ and others suggesting that patients without these features can also do well³⁰. That the classic distinction between neurotic and psychotic depression appears less helpful in this group as a predictor of good response is nothing new. Post³¹ in 1976 stressed the practical irrelevance of any subclassification of elderly depressives, as he found that ECT rendered severe psychotic depressives fit for discharge only slightly more often than neurotic depressives. The presenting picture of apparent hysterical illness, hypochondriasis or other apparent neurotic illness may well be caused by an underlying functional psychosis, often depressive in the elderly. More recently, in a study of 163 elderly patients given ECT, it was found that 27% had predominantly neurotic depressive features and yet had a good response to treatment⁴. In fact, in the study by Fraser and Glass³², psychic anxiety, along with the more expected features of short duration, severity of illness, guilt and agitation, was one of the symptoms correlated with a favourable response to ECT, whereas the typical endogenous features of late insomnia and diurnal variation in mood were not. Older patients with treatment-resistant depression often do respond to ECT, although not as well as non-resistant patients³³. However, they do respond better to ECT than to SSRIs²⁹ and Flint⁶ found that ECT was significantly superior to tricyclic/neuroleptic combinations, even when the former had been augmented with lithium. A pragmatic consensus would suggest that in the elderly a trial of ECT is indicated in any depressed patient who might otherwise be regarded as a treatment non-responder, and if the illness is severe and of short duration there is likely to be a good response, regardless of the presenting symptoms. If the illness has been present for a long time, it still may respond, particularly if there is a clear history of a recent change for the worse in a patient who had previously maintained a stable personality and had coped normally with the vicissitudes of life. Prolonged or abnormal bereavement reactions with marked depressive features not responding to antidepressants or talking therapies may need to be treated with ECT before psychotherapy or counselling can be effective. ECT may need to be given within a few months of the loss if hopelessness and suicidal ideation suggest a risk to life, and should not be withheld due to the feeling that the patient must work through his/her grief naturally, as he/she may never get that chance.

Continuation Pharmacotherapy after ECT

High relapse rates of depression have been consistently reported after remission with ECT. Five controlled trials have demonstrated the efficacy of continuation treatment with antidepressants and lithium in reducing relapse after remission with ECT³⁴. Further RCTs have demonstrated the efficacy of continuation treatment with imipramine and paroxetine in relapse prevention in such patients³⁵. Nortriptyline monotherapy and its combination with lithium has also been shown to be superior to placebo over six months in preventing relapses in unipolar depression following remission with ECT³⁶.

A recent study used a longitudinal, randomized, single-blind design to compare by survival analysis the two-year outcome of two subgroups of elderly patients with psychotic unipolar depression who were ECT (plus nortriptyline) remitters³⁷. The mean survival time was significantly longer in the combined ECT plus nortriptyline subgroup than in the nortriptyline subgroup. No differences were observed between treatments with regard to tolerability. The authors advocated the judicious use of combined continuation/maintenance ECT and antidepressant treatment in elderly patients with psychotic unipolar depression who are ECT remitters.

Schizophrenia

Paraphrenia will often respond to ECT³⁸, although this is more likely if there are obvious depressive symptoms or delusions. A Cochrane Review assessed the evidence for the efficacy of ECT in terms of clinically meaningful benefits in patients with schizophrenia, and whether variations in the practical administration of ECT influences outcome³⁹. The Review included 24 trials and 46 reports and showed the following:

Fewer patients remain unimproved with ECT, with less relapses and earlier discharge than patients treated with placebo or simulated ECT.
Limited data indicated visual memory impairment with ECT compared with simulated ECT.
ECT is less beneficial than antipsychotic medication.
Continuation ECT added to antipsychotics is superior to antipsy- chotics alone but is associated with more memory impairment.

There is relatively little evidence specific to the use of ECT in older patients with schizophrenia. ECT has been shown to have good short-term effects and be safe in middle-aged and elderly patients with intractable catatonic schizophrenia⁴⁰ and in treatment-resistant schizophrenia⁴¹.

In schizophrenia, the NICE Review²⁶ of the data from 25 RCTs indicated that ECT may be effective in acute episodes of certain types of schizophrenia and reduces the occurrence of relapses. However, the results were not conclusive and the design of many of the studies did not reflect current practice. Moreover, there are no RCTs of ECT compared with antipsychotics. Furthermore, studies that include patients with treatment-resistant schizophrenia had not reported the use of clozapine. The Review concluded that ECT alone is not more effective than antipsychotic medication but that the combination of ECT and pharmacotherapy may be more effective than pharmacotherapy alone although the evidence is not conclusive.

ECT is certainly useful in the depressed (and usually elderly) patient with Parkinson’s disease, as the motor symptoms will improve as well as the depression, and indeed, some authors advocate ECT as the treatment of choice for certain stages of Parkinson’s disease, whether or not depression is a major problem⁴²‘⁴³. I have given daily ECT with excellent results to a Parkinsonian patient who had developed severe paranoid delusions. His refusal to accept his medication rendered him rigid and immobile with pressure sores, he needed intravenous fluids and nasogastric feeding until he had four treatments, whereupon his physical and emotional improvement was dramatic.

Fogel²⁷ suggests that ECT might be more readily used in the elderly if we were more objective about its virtues as compared with the severe side effects often associated with neuroleptics, which are quite readily used in the agitated elderly patient. Extrapyramidal effects were usually the limiting factor but are not so noticeable with atypical neuroleptics. However, he postulates that the demented patient who is very agitated and screaming might suffer less indignity and fewer side effects if treated with ECT, rather than tranquillizers, as the patient may have an underlying affective disturbance manifest only by the agitation and negativism that one often sees in this condition.

Mania

Mania is another potential indication for a trial of ECT⁴⁴, particularly in the elderly, where neuroleptics may fail to control the symptoms and yet produce unsteadiness, postural hypotension or falls, and lithium may not be tolerated due to toxicity problems.

The NICE Review²⁶ of four RCTs indicated that ECT may be of benefit in rapid control of mania and catatonia, a suggestion that is supported by the results of observational studies. Overall, however, it concluded that the evidence for the effectiveness of ECT and for the determination of the most appropriate therapeutic strategy is inconclusive. In contrast, a recent literature review of continuation and maintenance ECT in treatment-resistant bipolar disorder reported good evidence for efficacy⁴⁵. ECT is indicated in severe and prolonged mania (excitement, delirium, psychosis, or rapid-cycling manic states), especially when the anti-manic medications (lithium, neuroleptics) have been relatively inefficient⁴⁶. It seems that the NICE Review has been restrictive in the studies it considered and the conclusions drawn from them. It must also be emphasized that the evidence reviewed above is not specific to elderly people.

CONTRAINDICATIONS

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