76: Electroconvulsive Therapy

Published on 06/02/2015 by admin

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CHAPTER 76 Electroconvulsive Therapy

Philip R. Levin, MD, Alma N. Juels, MD

1 What are the major indications for electroconvulsive therapy treatment?

Electroconvulsive therapy (ECT) treatment plays an important role in treating severe and medication-resistant depression with psychotic features, manic delirium, and catatonia. ECT has been noted to result in a prompt improvement in symptoms of depression. Some studies have shown ECT to be more effective than antidepressant medications alone in treating the psychotic subtype of depression. ECT also remains a treatment option for patients with schizophrenia who do not respond to pharmacologic treatment.

2 What are the downsides of antidepressant medication?

Although antidepressant medications are effective for many patients, the rate of response to the first agent administered can be as low as 50%. The elderly may not be able to tolerate depressant medications because of the inability to tolerate the many side effects associated with antidepressant medications. In addition, certain neuronal changes in the elderly can decrease the response to medications.

3 What are the proposed mechanisms by which electroconvulsive therapy is effective?

Although its mechanism of action remains unclear, ECT increases cortical γ-aminobutyric acid concentration and enhances serotonergic function.

4 Has electroconvulsive therapy always been considered a good treatment for depression?

ECT was first used as a treatment for psychiatric disorders in the 1930s. However, complications such as fractures and cognitive impairment raised serious concerns. If not dangerous (use of insulin to cause a hypoglycemic seizure), it was barbaric (no anesthetic agents or muscle relaxants were used). Its use declined when antidepressant medications were introduced. In recent decades further research and technical advances have led to a renewed interest in the role of ECT.

5 How safe is electroconvulsive therapy?

It is estimated that death associated with ECT occurs in one of 10,000 patients. Interestingly, ECT appears to have less morbidity and mortality compared to many antidepressant medications. Because of this strong safety record, patients with significant comorbidities are often candidates for ECT.

6 What is the physiologic response to electroconvulsive therapy?

During ECT a generalized seizure is induced, leading to an acute increase in cerebral blood flow and an associated increase in intracranial pressure (ICP). Immediately following the ECT stimulus, there is a marked transient parasympathetic response that may induce sinus bradycardia, other bradyarrhythmias, asystole, premature atrial or ventricular contractions. This is rapidly followed by a more prominent sympathetic response, resulting in an increase in heart rate of 20% or more and increases in blood pressure of 30% to 40% or more. Ventricular arrhythmias and ST-segment changes may be noted and tend to be self-limited. The duration of the tachycardia tends to correlate with the seizure duration as measured by electroencephalography (EEG), although hypertension often persists and requires therapy. Increases in adrenocorticotropic hormone, cortisol, epinephrine, vasopressin, prolactin, and growth hormone are noted. Intraocular pressure and intragastric pressure also transiently increase.

7 What patients are at increased risk for complications after electroconvulsive therapy?

ECT should be used cautiously if at all when the effects on cerebral blood flow, ICP, heart rate, and blood pressure may prove problematic to the patient because of coexisting disease. Thus patients with cerebral space-occupying lesions or cerebrovascular disease are at increased risk. Similarly patients with unstable cardiac disease, including patients with uncompensated congestive heart failure, severe valvular disease, unstable angina, recent myocardial infarction, and uncontrolled hypertension are all at increased risk of complications. Patients with pheochromocytoma should not receive ECT because massive amounts of epinephrine or norepinephrine may be released into the circulation. ECT has been used safely in persons with cardiac pacemaker or implantable cardiodefibrillators and during pregnancy.

8 What type of preoperative evaluation is necessary before electroconvulsive therapy treatment?

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