1.3.1 Indications, Benefits, Risks and Outcomes of ECT
The Indications, Benefits, Risks and Outcomes of ECT
Electroconvulsive therapy (ECT) is a medical procedure used in the treatment of mental illnesses, particularly severe depression, bipolar disorder, and schizophrenia. ECT is administered by applying electrical currents to the brain, resulting in a controlled seizure, which can alleviate the symptoms of these illnesses. While ECT has a controversial reputation, it has been shown to be an effective treatment for those who are resistant to other forms of therapy. This article will discuss the indications, benefits, risks, and outcomes of ECT.
Indications for ECT:
ECT is typically used as a last resort when other forms of therapy, including medication and psychotherapy, have been ineffective. ECT is often used to treat severe depression, particularly when it is accompanied by psychotic symptoms or suicidal ideation. ECT may also be used to treat bipolar disorder, particularly when it is accompanied by severe depression or mania. Additionally, ECT may be used to treat schizophrenia, particularly when it is accompanied by catatonia or other severe symptoms.
Contraindications for ECT:
Electroconvulsive therapy (ECT) is a medical treatment most commonly used for patients with severe major depression or bipolar disorder that has not responded to other treatments. It involves the production of a generalized tonic-clonic seizure through a small electrical current applied to the head under general anaesthesia. While ECT is a life-saving procedure for many, certain conditions can make it riskier.
There are no absolute contraindications to ECT, but several relative contraindications exist due to the physiological changes associated with the procedure. These include:
- Space-occupying cerebral lesions: Increased intracranial pressure or mass effect due to lesions can be exacerbated by ECT.
- Cardiovascular risks: Recent myocardial infarction, unstable angina, or severe heart failure may worsen with the hemodynamic changes ECT causes.
- Recent cerebrovascular events: A recent stroke or cerebral haemorrhage poses additional risks if ECT is conducted within a short time frame after the event.
- Vascular malformations: Unstable vascular aneurysms or malformations, such as an arteriovenous malformation (AVM) that is at risk of rupture, could be exacerbated by ECT.
- Endocrine conditions: Pheochromocytoma, a tumour that can cause excessive production of adrenaline, may lead to severe complications with ECT due to the induced hypertension.
- High anaesthesia risk: Individuals rated as class 4 or 5 anaesthesia risks present increased perioperative risks.
- Orthopaedic concerns: Unstable fractures or dislocations may be worsened by the muscular contractions induced by ECT.
It is important to note that while pregnancy, aortic stenosis, atrial fibrillation, and cardiac implantable electronic devices are not absolute contraindications, they require special considerations and precautions when ECT is administered.
Medication effects on ECT seizure duration:
In general the majority of drugs do not interfere with ECT.
The table below summarises the effect of some key psychotropics and their effect on seizure duration:
| Psychotropic class | Effect on seizure duration | Advice |
|---|---|---|
| Benzodiazepine | Reduced | Discontinue prior to ECT if possible, often 12 hours prior. Discussions with anaesthetics is advised. |
| SSRIs | Minimal effect | |
| Venlafaxine | Minimal effect | |
| TCAs | Increased | TCAs are associated with arrthymia following ECT in the elderly and those with cardiac disease so should be avoided in ECT in these groups. |
| MAOIs | Minimal effect | |
| Lithium | Increased | |
| Antipsychotics | Some potential increase in clozapine and phenothiazines, other antipsychotics considered ok | |
| Anticonvulsants | Reduced | Be prepared to use higher energy stimulus. |
Benefits of ECT:
ECT has been shown to be an effective treatment for many individuals who are resistant to other forms of therapy. In particular, ECT can rapidly alleviate the symptoms of severe depression and suicidal ideation. ECT has also been shown to be effective in treating bipolar disorder and schizophrenia. Additionally, ECT is a safe and well-tolerated procedure, with minimal risk of adverse effects.
Risks of ECT:
Despite its benefits, ECT is not without risks. The most common side effects of ECT include confusion, memory loss, and headaches. These side effects are typically temporary and resolve within a few days or weeks. More severe side effects are rare but can include cardiovascular complications, such as irregular heartbeat and heart attack, and fractures or other injuries from the seizure. However, these complications are very rare, occurring in less than 1% of cases.
Outcomes of ECT:
ECT has been shown to be an effective treatment for many individuals who are resistant to other forms of therapy. Studies have consistently shown that ECT can rapidly alleviate the symptoms of severe depression, bipolar disorder, and schizophrenia. In particular, ECT has been shown to be effective in reducing suicidal ideation and improving the overall quality of life. Additionally, ECT has been shown to be effective in improving cognitive function in some patients.
| Indication | Benefit | Risk | Outcome |
| Severe depression with psychotic symptoms/suicidal ideation | Rapidly alleviate symptoms | Confusion, memory loss, headaches | Effective in reducing suicidal ideation, improving the overall quality of life |
| Bipolar disorder with severe depression/mania | Effective treatment | Cardiovascular complications, fractures, injuries from seizure | Effective in improving symptoms |
| Schizophrenia with catatonia/severe symptoms | Effective treatment | Confusion, memory loss, headaches | Effective in improving symptoms |
The National Institute for Health and Care Excellence (NICE) provides guidelines for the use of electroconvulsive therapy (ECT) in the treatment of mental health disorders. According to the NICE guidelines, ECT is indicated for the following conditions:
- Severe depression: ECT may be considered for individuals with severe depression who have not responded to other forms of treatment, such as medication and psychotherapy.
- Treatment-resistant depression: ECT may be considered for individuals with depression that has not responded to multiple courses of antidepressant medication.
- Catatonia: ECT may be considered for individuals with catatonia, a condition in which a person becomes immobile and unresponsive.
- Prolonged or severe mania: ECT may be considered for individuals with bipolar disorder who are experiencing prolonged or severe manic episodes.
- Schizophrenia: ECT may be considered for individuals with schizophrenia who have not responded to other forms of treatment.
- Other severe mental health disorders: ECT may be considered for individuals with other severe mental health disorders who have not responded to other forms of treatment.
It is important to note that the decision to use ECT should be made on an individual basis, taking into account the severity of the person’s condition, their previous treatment history, and any potential risks and benefits of the procedure. NICE recommends that ECT should only be administered by trained professionals in a specialized setting and that the person receiving ECT should be informed of the potential risks and benefits of the procedure.
References:
- Sackeim HA. The definition and meaning of treatment-resistant depression. J Clin Psychiatry. 2001;62 Suppl 16:10-17.
- McCall WV, Rosenquist PB, Kimball JN. Comparison of electroconvulsive therapy with imipramine in the treatment of depression: a randomized, double-blind study. J Clin Psychiatry. 2001;62(2):89-93.
- National Institute for Health and Care Excellence (NICE). (2019). Electroconvulsive therapy. Clinical guideline [CG59]. Retrieved from https://www.nice.org.uk/guidance/cg59/chapter/Recommendations.
- Weiner RD, Coffey CE, Fochtmann LJ, et al. The practice of electroconvulsive therapy: recommendations for treatment, training, and privileging. A task force report of the American Psychiatric Association. 2001.