CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 • NUMBER 9 SEPTEMBER 2007

679

MAYUR PANDYA,DO

Psychiatric Neuromodulation Center,Cleveland Clinic

Electroconvulsive therapy:What the internist needs to know

REVIEW

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ABSTRACT

Although electroconvulsive therapy (ECT) is widely usedto treat a number of psychiatric disorders,manyphysicians are still unfamiliar with the procedure,itsindications,and its contraindications.This article is aninternist’s guide to ECT,with particular focus on howcommonly prescribed medications and medical conditionsaffect ECT.

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KEY POINTS

ECT is safe and works rapidly,making it a primarytherapy in situations requiring acute intervention.Anotherreason to consider ECT is a history of poor response tomedications or of adverse effects with medications.Although ECT was first used in patients withschizophrenia,it is most often used today for mooddisorders,including unipolar depression,bipolardepression,and acute mania.Before ECT is performed,patients require a medicalevaluation to undergo anesthesia,and some may needspecial consultation.Vagus nerve stimulation is the newest neuromodulatorytechnique to receive approval for adjunctive treatment of depression.Experimental treatments that show promiseinclude deep brain stimulation and repetitive transcranialmagnetic stimulation.

LECTROCONVULSIVETHERAPY

(

ECT

) hasan undeservedly bad reputation. This isunfortunate. As currently performed, ECT issafe and is effective for treating a number of psychiatric disorders. For some patients, it isthe only therapy that works.The following article outlines the indica-tions for and contraindications to ECT and spe-cial considerations for patients referred for it.

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TREATING MENTAL ILLNESSBY INDUCING SEIZURES

In 1927, Wagner-Jauregg won the Nobel Prizefor curing patients with “dementia paralytica”(tertiary syphilis) by infecting them withmalaria. The concept that one illness could betreated by inducing another led von Medunain 1934 to perform the first reported convul-sive therapy in psychiatry.

Von Meduna, a neuropathologist, hadnoted that patients with epilepsy had moreglial cells than average, and patients withschizophrenia had fewer. He had also seendata that few patients had both schizophreniaand epilepsy (not true), and that when peoplewith mental disorders suffered seizures, theirmental condition often improved. He rea-soned that if he could induce seizures inpatients with schizophrenia by injecting cam-phor, their glial cells might increase, and theirsymptoms might improve. And in fact, in hisinitial work, symptoms of schizophreniaimproved partially to completely.In 1938, the Italians Bini and Cerlettiperformed the first documented electricalinduction of seizures in humans.

One yearlater, ECT was introduced to the UnitedStates. Until effective antipsychotic drugs

LEOPOLDO POZUELO,MD

Section Head,Consultation Liaison Psychiatry,Department of Psychiatry and Psychology,Cleveland Clinic

DONALD MALONE,MD

Section Head,Adult Psychiatry,MedicalDirector,Psychiatric Neuromodulation Center,Cleveland Clinic

Dr.Malone has obtained research funding from and is a consultant for Medtronic,Inc.

CREDIT

CME

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CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 • NUMBER 9 SEPTEMBER 2007

were developed in the 1950s, the only effec-tive alternatives to ECT were insulin shocktherapy and lobotomy, which was falling outof favor.In the early years, the lack of adequateanesthesia or muscle relaxation resulted infractures or dislocations, often with negativerecollection for the event. Lack of knowledgeregarding the dose parameters of electricalstimulation led to more cognitive side effects.Over the decades, the safety and efficacyof ECT have been improved and its indica-tions have been defined. Today, it is usuallydone with the patient under general anesthe-sia, and with muscle relaxants and cardiopul-monary monitoring, which have reduced itscomplications. Nevertheless, ECT’s historicalbeginnings, combined with its negative por-trayal in the media,

have left some patientsfearful and hesitant to undergo ECT if theyneed it.

How ECT works is unknown

Although many mechanisms have been pro-posed, how ECT works remains unknown. Anattractive hypothesis to account for ECT’seffects on depression is that it alters serotoninand dopamine activity.

4,5

Changes in gamma-aminobutyric acid (GABA) and noradrena-line levels have also been reported.

4,6

Mostlikely, the therapeutic effects of ECT are aresult of a combination of neurotransmitteralterations.

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MOST OFTEN USEDFOR MOOD DISORDERS

ECT was first used in patients with schizo-phrenia, and today, treatment-resistant psy-chosis is still considered an appropriate indica-tion for it. Today, however, ECT is most oftenused for mood disorders, including unipolardepression, bipolar depression, and acutemania.The

Diagnostic and Statistical Manual of Mental Disorders

defines major depression as aconstellation of symptoms, which may includedepressed mood, anhedonia, sleep distur-bance, psychomotor retardation or agitation,fatigue, guilt, poor concentration, and suici-dality.

The symptoms result in marked socialand occupational impairment, commonlyresulting in interpersonal and financial dis-tress. According to the Global Burden of Disease Study, depression ranks as the fourth-leading cause of disability worldwide.

Initialtherapies consist of drugs and psychotherapy,alone or in combination. Patients with depres-sion that is moderate to severe and resistant todrug treatment may be referred for ECT,which is often considered the gold standardantidepressant treatment.Most patients should undergo an adequatetrial of oral drug therapy before being referredfor ECT. The actual number of drugs thatshould be tried and for how long are deter-mined on a case-by-case basis; in general, oneshould try different classes of antidepressantsand various augmentation techniques beforeturning to ECT. Poor response to medicationsor adverse effects with pharmacotherapy maybe reasons to consider ECT.On the other hand, ECT’s safety and rapidefficacy make it a good primary treatment insituations requiring acute intervention, suchas catatonia and psychiatric exacerbationsduring pregnancy.All patients being considered for ECTshould receive a general psychiatric evalua-tion. The psychiatrist will then proceed withreferral for ECT if appropriate and recom-mend any necessary workup (discussedbelow).

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ECT REQUIRES MEDICAL ASSESSMENT

Although no absolute contraindications toECT exist, several conditions are associatedwith an increased risk of complications andeven death (see below). The cardiovascular,central nervous, and pulmonary systems carrythe highest risks from general anesthesia andthe induction of generalized seizure activity.In most routine cases, the patient under-goes routine clearance for anesthesia, but spe-cial considerations may necessitate consulta-tion with medical specialists such as a cardiol-ogist, neurologist, neurosurgeon, endocrinolo-gist, anesthesiologist, or dentist. All casesreferred for ECT require analysis of the med-ical risks of treatment (discussed below).The pre-ECT evaluation includes basictests such as a complete blood cell count,serum electrolyte levels, renal function tests,

ELECTROCONVULSIVE THERAPYPANDYA AND COLLEAGUES

ECT is farsafer nowthan in the past

and electrocardiography. Neuroimaging, chestradiography, and spine films are not routinelydone unless clinically indicated. For example,spine films may be necessary in some patientswho are elderly or who have osteoporosis.Compression fractures are not an absolutecontraindication to ECT, but the physicianperforming ECT would want this informationso that he or she can make sure to provideadequate paralysis. Careful attention shouldalso be paid to the teeth, with dental consul-tation obtained if needed.Before ECT, electrolyte levels should bestabilized and appropriate fluid status main-tained.

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SOME ECT PATIENTSNEED SPECIAL CONSIDERATION

According to the American PsychiatricAssociation’s Task Force on ElectroconvulsiveTherapy,

patients with certain medical con-ditions may require more extensive workupand consideration during ECT (

TABLE 1

Patients with autonomic sensitivity

Seizure induction causes acute cardiopulmonarychanges, including some initial parasympatheticbradycardia. This is followed by a sympatheticsurge, causing transient tachycardia and hyper-tension. The sympathetic surge occurs only if aseizure is induced. Thus, patients at risk of brady-cardia (eg, those on beta-blockers) may be par-ticularly prone if stimulation is given but aseizure is not induced. To counteract theparasympathetic effect, some physicians give ananticholinergic drug—atropine or glycopyrro-late (Robinul)—although this is not routine orrequired.These autonomic effects make patientswith a number of cardiovascular and neuro-logic conditions particularly vulnerable toexacerbation and increased risk of death.These conditions include increased intracra-nial pressure, recent stroke, recent myocar-dial infarction, unstable angina, uncon-trolled hypertension, severe valvular disease,decompensated congestive heart failure, frag-ile aneurysm, and significant arrhythmia.Recommended management for patientswith many of these conditions includes func-tional cardiac testing before the procedureand giving an antihypertensive agent (eg,intravenous labetalol or esmolol) during theprocedure to blunt the sympathetic responsein patients at high risk.Patients with chronic atrial fibrillationcan undergo ECT safely. Therapeutic antico-agulation should be continued throughout theECT course.Other conditions that pose increased riskare clinically evident hyperthyroidism (inwhich ECT may result in thyroid storm),pheochromocytoma, and narrow-angle orclosed-angle glaucoma. However, ECT hasbeen successfully performed in all of the aboveconditions, and therefore the condition aloneshould not exclude appropriate patients fromECT.A cardiology consultation is also recom-mended for patients with pacemakers orimplantable cardioverter-defibrillators (ICDs);these patients can undergo ECT safely if thedevice has been checked recently. Dependingon the type of pacemaker, it may have to be

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Conditions requiring special considerationbefore electroconvulsive therapy

Conditions associated with autonomic sensitivity

Clinically evident hyperthyroidismDecompensated congestive heart failureElevated intracranial pressureFragile aneurysmNarrow-angle or closed-angle glaucomaPheochromocytomaRecent myocardial infarctionRecent strokeSevere valvular diseaseSignificant arrhythmiaUncontrolled hypertensionUnstable angina

Conditions associated with sensitivity to anesthesia

Amyotrophic lateral sclerosisGenetic or acquired pseudocholinesterase deficiencyMyasthenia gravisNeuroleptic malignant syndromePorphyriaPregnancy

Conditions associated with cognitive sensitivity

DementiaTraumatic brain injury

TABLE 1