Evidence-Based Reviews

When is ECT indicated in psychiatric disorders?

Current Psychiatry. 2002 February;1(2):21-26

References

1. American Psychiatric Association. Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. 2nd ed. Washington, D.C.: American Psychiatric Association; 2001.

2. Roberts JM. Prognostic factors in the electroshock treatment of depressive states I. Clinical features from history and examination. J Ment Sci. 1959;105:693-702.

3. Sackeim HA, Rush AJ. Melancholia and response to ECT (letter). Am J Psychiatry. 1995;152(8):1242-1243.

4. American Psychiatric Association. Diagniositc and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994.

5. Sobin C, Prudic J, Devanand DP, Nobler MS, Sackeim HA. Who responds to electroconvulsive therapy? Br J Psychiatry. 1996;169:322-328.

6. Hickie I, Mason C, et al. Prediction of ECT response: validation of a refined sign-based (CORE) system for defining melancholia. Br J Psychiatry. 1996;169(1):68-74.

7. Abrams R. Electroconvulsive Therapy. 3rd ed. New York: Oxford University Press; 1997.

8. Bush G, Fink M, Petrides G, et al. Treatment with lorazepam and electroconvulsive therapy. Acta Psychiatr Scand. 1996;93:137-143.

9. Ungvari GA, Leung CM, Wong MK, Lau J. Benzodiazepines in the treatment of catatonic syndrome. Acta Psychiatr Scand. 1994;89:285-288.

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11. Black DW, Winokur G, Nasrallah A. A multivariate analysis of the experience of 423 depressed inpatients treated with electroconvulsive therapy. Convulsive Ther. 1993;9:112-120.

12. Tew JD, Jr, Mulsant BH, Haskett RF, et al. Acute efficacy of ECT in the treatment of major depression in the old. Am J Psychiatry. 1999;156:1865-1870.

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14. Daly JJ, Prudic J, Devanand DP, et al. ECT in bipolar and unipolar depression: differences in speed of response. Bipolar Disorders. 2001;3(2):95-104.

15. Prudic J, Haskett RF, Mulsant B, et al. Resistance to antidepressant medications and short-term clinical response to ECT. Am J Psychiatry. 1996;153(8):985-992.

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18. Mukherjee S, Sackeim HA, Schnur DB. Electroconvulsive therapy of acute manic episodes: a review of 50 years’ experience. Am J Psychiatry. 1994;151:169-176.

19. Small JG, Klapper MH, et al. Electroconvulsive treatment compared with lithium in the management of manic states. Arch Gen Psychiatry. 1988;45:727-732.

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22. Chanpattana W, Chakrabhand ML, Sackeim HA, et al. Continuation ECT in treatment-resistant schizophrenia: a controlled study. J ECT. 1999;15:178-192.

23. Sackeim HA, Prudic J, Devanand DP, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral ECT at different stimulus intensities. Arch Gen Psychiatry. 2000;57:425-434.

24. Shapira B, Tubi N, Drexler H, Lidsky D, Calev A, Lerer B. Cost and benefit in the choice of ECT schedule. Twice versus three times weekly ECT. Br J Psychiatry. 1998;172:44-48.

25. Rasmussen KG, Richardson JR, Rummans TA. ECT in the medically ill. Psychiatric Clin North Amer (in press).

In modern practice, various anticonvulsants have become common for treating mania, and no comparative data between such agents and ECT are available. ECT is reserved for highly agitated, medication-refractory patients. The typical scenario entails a patient who does not respond to high doses of parenteral sedatives or antipsychotics, is in restraints much of the time, and is not cooperating with orally administered medications. In such circumstances, court-ordered approval for ECT is usually needed. Fortunately, in my experience bilateral ECT is almost universally effective for such patients, who are often grateful for their treatment once they achieve euthymia.

Rare uses of ECT in schizophrenia

ECT was commonly used for schizophrenia as well as mania before the advent of neuroleptics⁷ but is only rarely used for this indication in modern times. Here are the exceptions:¹

For acute exacerbations, especially with florid-positive symptoms such as delusions, hallucinations, disorganized thoughts and behavior, or catatonia. ECT can be remarkably effective in rendering patients compliant with oral medication. From there, patients can be discharged and can proceed with outpatient therapy.
For the chronically ill patient, if multiple medication trials fail to achieve optimum results. When administered in combination with antipsychotic medication, a trial of ECT may extend whatever benefits accrue from medication.⁷ In particular, the combination of ECT and neuroleptic medication may be more effective in such cases than either ECT or medication alone.²¹

Especially for chronically ill patients with schizophrenia, any benefits of an acute course of ECT will likely be short-lived unless maintenance ECT is instituted. In a well-designed study of schizophrenic patients stabilized with a combination of neuroleptic medication and an acute course of ECT, Chanpattana et al²² found that those maintained for 6 months with combination continuation ECT and pharmacotherapy did much better than did those randomly assigned to either modality alone.

Related resources

Abrams R. Electroconvulsive Therapy. 3rd ed. New York: Oxford University Press; 1997.
American Psychiatric Association. Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. 2nd ed. Washington, D.C.:American Psychiatric Association; 2001.
Mukherjee S, Sackeim HA, Schnur DB. Electroconvulsive therapy of acute manic episodes: a review of 50 years’ experience. Am J Psychiatry. 1994;151:169-176.

Drug brand names

Methohexital • Amidate, Brevital, Diprivan, Ethrane
Succinylcholine • Anectine

Disclosure

The author reports no affiliation or financial arrangement with any of the companies whose products are mentioned in this article.