When is electroconvulsive therapy (ECT) indicated?

Back to the case

Given the patient’s severe Parkinson’s disease and concurrent NMS, ECT was initiated. By the second treatment, fever and tachycardia resolved. By the sixth treatment, all NMS symptoms and associated paranoia had completely resolved and her Parkinson’s disease rating scale score went from 142 to 42. Her levodopa dose was reduced from 1,200 to 300 mg/day. She remained stable for years afterward.

Bottom line

ECT is both effective and well tolerated in patients who have received appropriate medical evaluation.

Dr. Lang is clinical associate professor in the departments of psychiatry and internal medicine and director of the electroconvulsive therapy and transcranial magnetic stimulation programs at East Carolina University, Greenville, N.C.

Key points

• ECT is indicated for psychotic and depressive disorders, with high efficacy and rapid response.
• ECT also has proven benefits for NMS, catatonia, delirium, status epilepticus, and Parkinson’s disease.
• Evaluation and focused treatment of relative contraindications maximizes both safety and tolerability of ECT.

References

1. Weiner R et al. “Electroconvulsive therapy in the medical & neurologic patient” in A Stoudemire, BS Fogel & D Greenberg (eds) Psychiatric Care of the Medical Patient, 2nd ed., New York, Oxford Univ Press. 2000:419-28. (Second edition is out of print.)

2. Baghai T et al. Electroconvulsive therapy and its different indications. Dialogues Clin Neurosci. Mar 2008;10(1):105-17.

3. Ozer F et al. Electroconvulsive therapy in drug-induced psychiatric states and neuroleptic malignant syndrome. J ECT. 2005 Jun;21(2):125-7.

4. Taylor S. Electroconvulsive therapy: A review of history, patient selection, technique, and medication management. South Med J. 2007 May;100(5):494-8.

5. The Practice of Electroconvulsive Therapy, 2nd edition. A Task Force Report of the American Psychiatric Association. 2001. pp. 84-85.

6. Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry. 1994 May;45(5):444-50.

7. Miller R et al. ECT: Physiologic Effects. Miller’s Anesthesia. 7th Edition. 2009.

8. Mueller PS et al. The Safety of electroconvulsive therapy in patients with severe aortic stenosis. Mayo Clin Proc. 2007 Nov;82(11):1360-3.

9. Dolenc TJ et al. Electroconvulsive therapy in patients with cardiac pacemakers & implantable cardioverter defibrillators. Pacing Clin Electrophysiol. 2004 Sep;27(9):1257-63.

Suggested readings

The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging (A Task Force Report of the American Psychiatric Association), 2nd Edition. APA Publishing. 2001.

Weiner R et al. “Electroconvulsive therapy in the medical & neurologic patient” in A Stoudemire, BS Fogel & D Greenberg (eds) Psychiatric Care of the Medical Patient, 2nd ed., New York, Oxford Univ Press. 2000:419-28. (Second edition is out of print.)

Rosenquist P et al. Charting the course of electroconvulsive therapy: Where have we been and where are we headed? J Psychosoc Nurs Ment Health Serv. 2016 Dec 1;54(12):39-43.

QUIZ

1. All of the following are indications for ECT except?

A. Schizophrenia.

B. Panic attacks.

C. Bipolar mania.

D. Catatonia.

Answer: B. Panic attacks. ECT is not effective for anxiety disorders including panic, generalized anxiety, PTSD, or OCD.

2. The most commonly accepted mechanism of action for ECT is?

A. Reduction in glutamate levels.

B. Altering signal transduction pathways.

C. Increased neurotransmitter activity.

D. Increased cerebral blood flow.

Answer: C. Increased neurotransmitter activity. There are data to support all, but neurotransmitter flow is most accepted thus far.

3. Which of the following is a common side effect of ECT?

A. Bronchospasm.

B. Diarrhea.

C. Delirium.

D. Visual changes.

Answer: C. Delirium. The rest are rare or not noted.

4. Which of the following is a relative contraindication for ECT?

A. Pregnancy.

B. Epilepsy.

C. Advanced age.

D. Increased intracranial pressure.

Answer: D. Increased intracranial pressure.