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electroconvulsive therapy (ECT)

A low-voltage alternating current is sent to the brain to induce a convulsion or seizure, which accounts for the therapeutic effect. Indications: 1) refractory major depression a) *very severe or psychotic/delusional depression b) *failure of 2 courses of drug therapy c) actively suicidal patients# d) previous good response to ECT 2) manic states that often are not responsive to medication treatment - treatment-resistant bipolar depression [9] 3) may be useful in treatment of catatonia 4) *may be helpful in depression overlapping with Parkinson's disease or Parkinson's dementia 5) may be useful in neuroleptic malignant syndrome * improves depression/functioning, interpersonal relationships, psychosis, & emotional lability in adolescent & young adult patients with major depression, bipolar disorder, & primary psychotic disorders [13] # ECT appears to be no better than other treatments at reducing short-term risk for suicide in high-risk patients [14] Contraindications: 1) no absolute contraindications 2) can be given to pregnant women 3) effective in the elderly [5] 3) anticoagulation is NOT a contraindication [5,6] 4) relative contraindications: a) intracranial space-occupying lesion b) increased intracranial pressure (most important caution) c) cardiovascular disease 1] myocardial infarction within 6 weeks 2] uncontrolled heart failure 3] cardiac arrhythmia 4] pacemaker is NOT a contraindication [5] d) uncontrolled hypertension e) unstable vascular aneurysm or malformation d) recent cerebral hemorrhage or infarction (within 3 weeks) f) severe pulmonary condition g) history of complications of general anesthesia h) uncontrolled intraocular pressure (glaucoma) Benefit/risk: - number needed to treat = 3 patients with treatment- resistant bipolar depression to benefit 1 patient [9] Procedure: 1) ECT is typically administered in a series of treatments 2-3 times/week until resolution or maximal improvement of symptoms 2) a treatment course generally consists of 6-12 treatments 3) continuation therapy for prevention of relapse [7] - 10 treatments at 1.5 X seizure threshold weekly for 4 weeks, biweekly for 8 weeks, monthly for 2 months 4) the ECT treatment team consists of a treating psychiatrist, an anesthetist & a recovery nurse 5) INFORMED CONSENT is mandated 6) general anesthesia with: a) endotracheal intubation b) IV access c) protection of the teeth & other oral structures d) ultra-brief light general anesthetic - i.e. methohexital e) skeletal muscle relaxant f) muscarinic anticholinergic agent 1] prevent vagally-mediated bradycardia or asystole 2] atropine 3] glycopyrrolate may be preferred in the elderly 7) monitor a) blood pressure b) electrocardiogram c) electroencephalogram 8) constant current brief pulse stimulus 9) unilateral, ultrabrief, pulsed ECT plus venlafaxine - follow with flexible ECT-medication strategy [10] Complications: 1) cardiovascular a) arrhythmia b) myocardial infarction c) hypertension d) vasovagal response e) congestive heart failure 2) general anesthesia 3) transient anterograde & retrograde amnesia 4) delirium a) generally resolves quickly b) falls may occur with delirium 5) transient decrease in arterial oxygen saturation 6) no evidence that ECT causes structural brain changes 7) most elderly with late-life depression receiving ETC show no cognitive decline at 6 months (25% refused cognitive testing) Biochemistry: 1) changes in neurotransmitters a) acetylcholine b) norepinephrine c) dopamine d) serotonin 2) down-regulation of beta-adrenergic receptors 3) may decrease Ca+2 levels in cerebrospinal fluid (CSF Management: 1) premedication with beta-blocker or other antihypertensive agent for patient at risk of myocardial ischemia 2) follow-up evaluation of cognitive function - subsequent ECT should be postponed until mental status returns to baseline 3) prognosis: - response rate is up to 90% [5]

Related

magnetic seizure therapy

General

clinical procedure

References

  1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 715-716
  3. Kelly & Zisselman, J Am Geriatrics Soc 48:560, 2000
  4. UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  5. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
  6. Mehta V et al, Safety of Electroconvulsive Therapy in Patients Receiving Long-term Warfarin Therapy, Mayo Clin Proc 79(11): 1396, 2004
  7. Kellner CH et al, Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: A multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry 2006, 63:1337 PMID: 17146008
  8. van der Wurff FB, Stek ML, Hoogendijk WJ, Beekman AT The efficacy and safety of ECT in depressed older adults: a literature review. Int J Geriatr Psychiatry. 2003 Oct;18(10):894-904. Review. PMID: 14533122
  9. Schoeyen HK et al. Treatment-resistant bipolar depression: A randomized controlled trial of electroconvulsive therapy versus algorithm-based pharmacological treatment. Am J Psychiatry 2014 Sep 15 PMID: 25219389 http://psychiatryonline.org/doi/abs/10.1176/appi.ajp.2014.13111517
  10. Yager J NEJM Journal Watch. July 20, 2016 Massachusetts Medical Society (subscription needed) http://www.jwatch.org - Kellner CH et al. Right unilateral ultrabrief pulse ECT in geriatric depression: Phase 1 of the PRIDE study. Am J Psychiatry 2016 Jul 15; PMID: 27418379 - Kellner CH et al. A novel strategy for continuation ECT in geriatric depression: Phase 2 of the PRIDE study. Am J Psychiatry 2016 Jul 15 PMID: 27418381
  11. Obbels J, Verwijk E, Vansteelandt K et al. Long-term neurocognitive functioning after electroconvulsive therapy in patients with late-life depression. Acta Psychiatr Scand 2018 Jul 12 PMID: 30003550 https://onlinelibrary.wiley.com/doi/abs/10.1111/acps.12942https://onlinelibrary.wiley.com/doi/abs/10.1111/acps.12942
  12. Weiss A, Hussain S, Ng B, Sarma S, Tiller J, Waite S, Loo C. Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of electroconvulsive therapy. Aust N Z J Psychiatry 2019 Apr 10 PMID: 30966782 https://journals.sagepub.com/doi/10.1177/0004867419839139
  13. Benson N, Seiner S, Bolton P et al. Acute phase treatment outcomes of electroconvulsive therapy in adolescents and young adults. J ECT 2019 Sep; 35:178-183. PMID: 30562200 https://insights.ovid.com/crossref?an=00124509-201909000-00011
  14. Peltzman T, Shiner B, Watts B et al. Effects of electroconvulsive therapy on short-term suicide mortality in a risk-matched patient population. J ECT 2020 Mar 20 PMID: 32205732 https://journals.lww.com/ectjournal/Abstract/publishahead/Effects_of_Electroconvulsive_Therapy_on_Short_Term.99067.aspx
  15. Espinoza RT, Kellner CH Electroconvulsive Therapy. N Engl J Med 2022; 386:667-672. Feb 17 PMID: 35172057 https://www.nejm.org/doi/full/10.1056/NEJMra2034954