Electroconvulsive therapy (ECT) has been stigmatized by past misapplication and overuse. Nonetheless, it remains an effective treatment for certain psychiatric disorders. The current status of ECT as a standard psychiatric treatment is the result of multiple factors, including the growth of the elderly population, the decreased length of inpatient psychiatric stays and the increased acceptance and understanding of psychiatric treatment by the general public.
When ECT is recommended for a patient, the family physician may be the one who provides medical clearance for the procedure, authorizes managed-care psychiatric referral, treats medical conditions during ECT and manages transient side effects after ECT. Since the side effects of ECT can be serious in some patients, it is critical that the family physician understand the nature of ECT, the standard work-up that should be performed before ECT is administered and the management of patients at risk for side effects. The family physician can also play a significant role in lessening the stigma attached to ECT by providing appropriate patient and family education.
Efficacy of ECT
Before ECT was introduced, seizures induced with camphor were found to help some schizophrenic patients. The first ECT treatments were performed by Cerletti and Bini in 1938 and were based on the notion that schizophrenia and seizure disorder could not coexist in the same patient.[1] As ECT research progressed, however, the psychiatric conditions most responsive to this form of treatment were found to be certain mood disorders, neuroleptic malignant syndrome,[2] intractable seizures[3] and Parkinson's disease.[4]
The use of ECT has been most extensively studied in patients with major depressive disorder unresponsive to antidepressant drug therapy. A major depressive disorder is characterized by the occurrence of at least five of the following melancholic symptoms, with these symptoms lasting more than two weeks: persistent depressed mood, anhedonia, weight loss or gain, sleep disturbance, psychomotor changes, fatigue, feelings of worthlessness, impaired concentration and suicidal ideation.[5] Guilt, loss of interest, agitation, anxiety, dysphoria, helplessness, worthlessness, and somatic and nihilistic delusions are the symptoms that are most responsive to ECT.[6] Depression accompanied by delusions of impoverishment, sin or guilt also responds well to ECT.[7]
The Agency for Health Care Policy and Research recently published a clinical practice guideline for the treatment of depression in primary care.[8] According to the guideline, antidepressant drugs should be used as first-line therapy, and ECT should be considered an alternative treatment for medication-resistant depression. Depressed patients who do not respond to adequate trials of antidepressant therapy may respond to ECT. In fact, ECT may be effective in 50 to 70 percent of psychiatric inpatients who have not responded to adequate antidepressant therapy.[8]
ECT is also an effective treatment for depressed patients with a coexistent condition in which the use of medication may be contraindicated or dangerous, such as pregnancy, stroke, dementia or cardiovascular disease. In a review[9] of 300 case reports of ECT use in pregnant women, this treatment was found to be relatively safe during pregnancy when it was undertaken with precautions. In another retrospective study,[10] nearly all of the 193 patients with depression following a stroke improved after they received ECT.
In addition, ECT can relieve depressive symptoms in demented patients with major depression.[11] Finally, ECT is safe and effective in patients who cannot tolerate antidepressant drugs because of cardiovascular problems such as conduction deficit or arrhythmias.[12]
ECT also alleviates the symptoms of mania associated with bipolar disorder. ECT is highly effective in manic patients who do not respond to medications such as lithium or anticonvulsants. Because ECT has a faster onset of action than pharmacotherapy, it provides expedient relief for severe, uncontrollable or dangerous manic episodes[13] (Table 1).
TABLE 1
Most dysrhythmias can be controlled with lidocaine (Xylocaine), given as an intravenous bolus (1 mg per kg) alone or as a bolus followed by a drip (1 to 4 mg per kg). Administration of lidocaine before ECT shortens seizure duration[24] and raises the seizure threshold.[25] Procainamide (Pronestyl) is a second-line choice for ventricular arrhythmias not fully controlled by lidocaine.
Cardiac Pacemaker. Under close supervision by a cardiologist, the patient with a cardiac pacemaker can be treated safely with ECT.[26,27]
NEUROLOGIC RISKS
Brain Tumor. A space-occupying lesion is a relative contraindication for ECT. Brain herniation can result from increased intracranial pressure associated with ECT.[28] ECT is Probably safe in depressed patients with small meningiomas that are not associated with headache or increased intracranial pressure.[29]
Cerebrovascular Accident. Fifty percent of patients experience depression in the first two years after a stroke. If antidepressant drug therapy fails in these patients, ECT may be effective.[30] ECT may be used safely one month after a cerebrovascular accident when adequate vascular stability has been reestablished.[10]
Seizure Disorder. Depressed patients with seizure disorder may be safely treated with ECT. However, the seizure threshold may be higher in patients with preexisting seizure disorder. Maintenance anticonvulsant drug therapy should be continued both before and during the treatment course. Status epilepticus following ECT may result from subtherapeutic anticonvulsant blood levels in patients with seizure disorder.[31]
REPRODUCTIVE RISKS
ECT may be used in pregnant women, and it can provide a safe alternative to drug therapy when the teratogenic effects of psychotropic medications are a significant risk factor. In 300 cases of ECT used during pregnancy, complications occurred in 28 cases.[9] Of these complications, three were stillbirths or neonatal deaths and five were miscarriages. Other side effects of ECT included transient benign fetal arrhythmias, mild vaginal bleeding, abdominal pain and self-limited contractions.
Based on this review, the investigator recommended that before ECT is administered to a woman during pregnancy, a pelvic examination be performed and non-essential anticholinergic medications be discontinued. He also recommended that these women undergo uterine tocodynamometry and that they receive intravenous hydration. In addition, the investigator recommended that pregnant women be given a nonparticulate antacid before ECT is administered, to prevent aspiration.
Adverse Effects
Confusion, a transient side effect of ECT, can range from disorientation to temporary retrograde and antegrade short-term memory impairment. While patients may have the subjective perception that their memory is permanently impaired, objective psychometric tests completed on patients months after treatment show that ECT has no permanent effects on memory functioning.[17,32-34]
In a review[35] of 16 studies that used pneumoencephalograms, CT scans, MRI scans and neuronal cell counts to identify changes in the structure of the brain due to ECT, no evidence indicated that ECT caused any structural or neuronal changes in the brain.
Final Comment
A course of ECT consists of six to 12 treatments, usually administered three times a week. Each single treatment may cost up to $1,500, which includes hospital, anesthesia and psychiatry charges; a course of ECT may cost between $9,000 and $18,000.
If maintenance antidepressant or lithium therapy is not used, symptoms relapse in 30 to 60 percent of patients within six months after ECT is completed.[17] Medications reduce relapse rates by 66 percent. A small number of patients require weekly or monthly maintenance ECT.
Family physicians should be aware that ECT is an effective treatment for selected psychiatric conditions, including major depression that does not respond to drug therapy. Recognition of these psychiatric conditions will enable expedient psychiatric referral for treatment. The family physician is in an excellent position to coordinate specialty medical care for patients considered for ECT. Finally, the family physician can aid compliance by educating the family about this useful treatment.
A patient information handout on electroconvulsive therapy appears on page 281.
The author thanks Dale D'Mello, M.D., Norbert Enzer, M.D., Jed Magen, M.D., Arnold Werner, M.D., and Ram Nagappan, M.D., for their helpfull review, of the manuscript. The author also acknowledges the secretarial support of Barbara Terry in the preparation of the manuscript.
REFERENCES
