A reasonable conclusion from these studies is that acutely catatonic patients should be treated first with a benzodiazepine such as parenteral and/or oral lorazepam, perhaps for up to 3 days, and then given ECT if response is insufficient. For patients with malignant catatonia—a particularly severe and life-threatening form of catatonia—ECT may need to be instituted sooner.10
Psychotic features Though the literature has been mixed on this subject, patients with psychotic depression have high response rates to an adequate course of ECT treatments. Hickie et al6 treated 81 depressed patients with ECT and performed in-depth analyses of a variety of clinical variables, including the presence of psychosis. Patients with psychotic depression were found to have a significantly higher rate of ECT response than those with nonpsychotic depression, though the latter still had high response rates.
ECT is considered a primary indication for patients with psychotic depression1,7 for two reasons:
- Response rates are uniformly high.
- If such patients were to receive pharmacotherapy, a neuroleptic with all the potential neurologic side effects inherent in such medication would be needed.
Further, clinical experience reveals that psychotically depressed patients tend to be particularly nonfunctional, to have lost weight, and to be suicidal. Thus, the rapid, definitive benefits of ECT are necessary as first-line therapy.
Age Age has been positively correlated with ECT outcome. Black et al,11 in an analysis of clinical predictors of ECT in several hundred patients, found that older patients responded more favorably to ECT than did younger ones. The study included careful assessments of pre- and post-ECT clinical status.
Tew et al,12 in a well-designed prospective study of several hundred ECT patients, found that those older than age 65 responded to ECT more favorably than those younger than 65. Possible mitigating factors in the younger group were greater medication nonresponsivity prior to ECT and longer illness severity. In another prospective study, Wilkinson et al13 also found superior response rates in patients older than 75.
At minimum, a consensus emerges from the literature that ECT response rates are at least as good in the elderly as in younger patients, an important finding given the often debilitating effects of depressive illness in this population and the high rates of medication nonresponse.
Potential for self-harm ECT is highly effective for suicidal or cachectic individuals. Decades of clinical practice have clearly established that acutely suicidal, depressed patients and those whose poor food and fluid intake has caused nutritional compromise represent urgent indications for ECT.1,7 In particular, recent research suggests that ECT response may be especially rapid in bipolar depressed patients.14
Medication resistance It is common practice for depressed patients to be given ECT after resistance to one or more medications is established. But recent research indicates that patients with medication-refractory depression respond to ECT at roughly half the rate of those who have not had an adequate antidepressant trial.15 Medication-resistant patients also have higher relapse rates post-ECT, even when they do initially respond.
Thus, particularly aggressive treatment regimens may be necessary for medication-refractory patients, including use of bilateral electrode placement and/or higher than usual electrical doses.
Another strategy would be to combine medications with ECT during the index course. While not studied prospectively, one retrospective comparison of ECT patients who were either given or not given concomitant nortriptyline suggests that such a strategy may enhance ECT efficacy.16
Personality factors Over the past few decades, patients with nonmelancholic depression have been variably referred to as neurotic, mood-reactive, hysterical, or personality-disordered. The difficulties inherent in precisely defining and measuring these variables make them difficult to apply to day-to-day practice. The more chaotic and unpredictable the patient’s emotional life, and the more mood-reactive the patient is to life events, the less the chance of substantial ECT benefit. In fact, a recent study indicates that depressed patients with personality disorders, especially from DSM-IV cluster B,4 have lower acute ECT response rates and higher post-ECT relapse rates than do depressed ECT patients without personality disorders.17
ECT: first choice for highly agitated manic patients
From the early days of ECT, it rapidly became the mainstay for treating severe, life-threatening manic states until the advent of neuroleptic drugs in the late 1950s. Large, retrospective studies have shown ECT to be highly effective for manic states.18
Two prospective, random assignment trials in particular document the modality’s efficacy. Small et al19 randomly assigned manic patients to either lithium treatment or ECT. While patients in both groups responded well, response was faster in the ECT group. Sikdar et al20 administered chlorpromazine and either real or sham ECT to manic patients and found that adding ECT to neuroleptic patients’ treatments substantially improved outcomes.