Unfortunately we don't fully support your browser. If you have the option to, please upgrade to a newer version or use Mozilla Firefox, Microsoft Edge, Google Chrome, or Safari 14 or newer. If you are unable to, and need support, please send us your feedback.
We'd appreciate your feedback.Tell us what you think! opens in new tab/window
Answer generated on June 4, 2024
The AI-generated responses are for illustration purposes only and should not be used for medical purposes.
Electroconvulsive therapy (ECT) is advised for severe and treatment-resistant mood disorders, including major depressive disorder with psychotic features, severe mania, bipolar depression, and catatonia, as well as in cases of severe suicidality or when medications are contraindicated, such as during pregnancy.[1-5]
ECT may be used as a last resort in pregnant patients with severe mania or depression when the health of the mother or fetus is at risk.[2]
ECT remains a critical option in the management of severe psychiatric conditions, particularly when other treatments have failed or are unsuitable. The procedure involves inducing generalized seizures under anesthesia, which requires careful monitoring and management of potential side effects such as cardiovascular changes and cognitive disturbances. The decision to use ECT should involve a thorough evaluation of the risks and benefits, considering the severity of the condition, previous treatment responses, and individual patient factors, including pregnancy and cardiovascular health. It is essential for healthcare providers to stay informed about the latest guidelines and safety protocols to optimize patient outcomes and minimize risks.
1.
Elsevier ClinicalKey Clinical Overview
Treatment Subsubsection Title: Procedures: Subsubsection Title: Electroconvulsive therapy: Subsubsection Title: General explanation: Most rapid and effective therapy for mania and bipolar depression Appropriately monitor the patient closely after therapy to prevent risk of mood destabilization or switching to mania Subsubsection Title: Indication: Severe and treatment-resistant bipolar depression Severe mania during pregnancy (although careful discussion of risks and benefits is crucial) Psychosis Suicidality Catatonia Patient preference for electroconvulsive therapy
2.
Elsevier ClinicalKey Clinical Overview
Treatment As a last resort, consider electroconvulsive therapy in patients with severe depression whose physical health or that of the fetus is at serious risk, or in situations in which the patient or fetus cannot wait until medications improve condition. This treatment requires stringent diagnostic and clinical indications If patient is already on long-term treatment: Ensure dose of medication is therapeutic and resolves symptoms and patient is taking medications as prescribed Exclude treatment nonadherence as cause of major depression If patient is taking lithium, ensure serum concentrations are in target range Consider initiating treatment as for medication-naive patients
3.
Lyness, Jeffrey M., Lee, Hochang B. (2024). In Goldman-Cecil Medicine (pp. 2336). DOI: 10.1016/B978-0-323-93038-3.00362-2
For acute episodes of mania (with or without coexisting psychotic symptoms), second- or first-generation antipsychotics (e.g., iloperidone)are more rapidly efficacious than mood stabilizers, with doses similar to their use for acute psychosis (seeTable 362-12). For acute treatment of bipolar depression, the evidence-based psychotherapies that are useful for unipolar depression are helpful, but antidepressants may precipitate mania. Therefore, patients in the depressive phase of illness should receive therapeutic doses of a mood stabilizer first, and antidepressant medication should used at the minimum dose for the minimum duration required. Supportive psychotherapy fosters compliance with maintenance treatments and helps patients manage psychosocial stressors, thereby minimizing their impact on precipitating mania or depression.Electroconvulsive therapy is useful for refractory maniaor depression and for patients with relative contraindications to medications, such as pregnancy.
For patients with psychotic depression, the addition of an antipsychotic medication (seeTable 362-12) to an antidepressant is more efficacious than either alone.For postpartum depression (Chapter 221), zuranolone (a neuroactive steroid that modulates gamma butyric acid receptors at 50 mg daily for 14 days) may be the preferred option. For medication-resistant major depression, expert consultation is required.Electroconvulsive therapyis the most effective treatment available and is the preferred approach for the most severe forms of major depression, especially major depression with psychotic features.,A single intravenous dose of ketamine may rapidly reduce severe depressive symptoms within 24hours,and esketamine nasal spray is effective for treatment-resistant depression.Ketamine appears to be as effective as electroconvulsive therapy for treatment-resistant major depression without psychotic features.However, ketamine can lead to a significant increase in symptoms of psychosis in normal volunteers and people with schizophrenia. Optimal management strategies after initial improvement with ketamine or esketamine remain to be determined. Deep brain stimulation is an investigational therapy for otherwise refractory depression. Overall evidence to date offers modest support for the efficacy of repetitive transcranial magnetic stimulation for depression, whereas transcranial direct current stimulation does not appear to be beneficial.Hallucinogenic drugs such as lysergic acid diethylamide (LSD), psilocybin,,and 3,4-methylenedioxymethamphetamine (MDMA) are experimental approaches that should be considered only under supervised conditions.
4.
Elsevier ClinicalKey Clinical Overview
Treatment Subsubsection Title: Procedures: Subsubsection Title: Electroconvulsive therapy: Subsubsection Title: General explanation: Generalized seizures are intentionally induced using electrical impulses Typically performed 2 to 3 times per week until clinical response is seen Average course is 6 to 12 treatments, which are administered under anesthesia and with muscle relaxants Subsubsection Title: Indication: May be used as first line therapy for patients who have: Psychotic depression Catatonia Previous response to this treatment method Severe suicidality Anorexia/rapidly deteriorating physical status Treatment-resistant depression Repeated medication intolerance Subsubsection Title: Contraindications: Relative contraindications Age younger than 18 years Space-occupying brain lesions Elevated intracranial pressure Recent myocardial infarction History of retinal detachment Pheochromocytoma Subsubsection Title: Complications: Associated with transient postictal confusion and a period of antegrade and retrograde memory loss Can cause a transient rise in heart rate, in cardiac workload, and in blood pressure Subsubsection Title: Repetitive transcranial magnetic stimulation: Subsubsection Title: General explanation: Magnetic fields stimulate nerve cells in the brain to improve symptoms of depression Evaluate patients for seizure risk before repetitive transcranial magnetic stimulation, including: Personal/family history of seizures or epilepsy Previous head injury or stroke with neurologic sequelae Current use of medications/substances that lower seizure threshold (eg, psychostimulants) or reduction in dose of medication with antiseizure properties (eg, benzodiazepine) Presence of medical condition or neurologic disorder that may lower seizure threshold (eg, electrolyte imbalance, sleep deprivation, drug withdrawal) Electromagnetic coil is held against the forehead and short electromagnetic pulses are administered through the coil
5.
Kellner CH, Obbels J, Sienaert P. When to Consider Electroconvulsive Therapy (ECT). Acta Psychiatrica Scandinavica. 2020;141(4):304-315. doi:10.1111/acps.13134.
Publish date: April 3, 2020.
OBJECTIVE: To familiarize the reader with the role of electroconvulsive therapy (ECT) in current psychiatric medicine. METHOD: We review clinical indications for ECT, patient selection, contemporary ECT practice, maintenance treatment and ECT in major treatment guidelines. RESULTS: ECT is underutilized largely due to persisting stigma and lack of knowledge about modern ECT technique. CONCLUSION: ECT remains a vital treatment for patients with severe mood disorders, psychotic illness and catatonia.
6.
Freedland, Kenneth E., Carney, Robert M., Lenze, Eric J., Rich, Michael W. (2022). In Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine (pp. 1841). DOI: 10.1016/B978-0-323-72219-3.00099-2
ECT is used for the treatment of severe depression in patients who have had multiple failed trials of psychotherapy and medication. ECT has an 80% response rate, which is better than for medications, works quickly (within 2 to 3 weeks), and is a safe procedure for most individuals. Cardiologists may be asked to assess patient safety for ECT, as it may cause brief but profound hemodynamic changes, including bradycardia (up to frank asystole, which may last for a few seconds), followed by tachycardia and hypertension. These effects usually resolve within 20 minutes. Rare complications include persistent hypertension, arrhythmias, asystole lasting more than 5 seconds, ischemia, and heart failure. Older age and preexisting CVD, including hypertension, coronary artery disease, heart failure, aortic stenosis, atrial fibrillation, and implanted cardiac devices are associated with increased complication rates. Patients undergoing ECT should be monitored throughout the procedure and until stable after the procedure. With appropriate monitoring and management of medications, almost all patients can safely complete treatment. While there are no absolute contraindications to ECT, the procedure should be delayed in patients who are hemodynamically unstable or who have new-onset or uncontrolled arrhythmias or hypertension. In patients with stable CHD and controlled hypertension, medications may be continued through the morning of the procedure. For patients with sustained post-ECT hypertension, antihypertensive therapy should be given after ECT and premedication used on the morning of subsequent ECT sessions; medications shown to be effective for this indication include labetalol, nicardipine, and clonidine. In patients with an implanted pacemaker, the pacemaker should be tested before and after ECT; a magnet should be placed at the patient’s bedside in the event that electrical interference leads to pacemaker inhibition and bradycardia. ECT appears safe in patients with an ICD.
