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Physical treatment

Electroconvulsive therapy

What’s new?

Allan IF Scott

• The Royal College of Psychiatrists published revised guidance
on the use of electroconvulsive therapy (ECT) in 2005
• This includes advice about the place of ECT in the treatment
of major depression and mania in contemporary practice
• The College wishes to promote the use of unilateral ECT in
non-urgent treatment

Abstract
This contribution is aimed at potential prescribers of electroconvulsive
therapy (ECT) and covers the place of ECT in the treatment of major
depression and mania in contemporary practice. The prescribing cycle is
discussed: the selection of electrode placement, and the frequency and
number of treatments. Adverse effects, outcome, and continuation treatment after ECT are also considered.

the seizure threshold approximated to the efficacy of bilateral
ECT with a dose 150% above threshold.3 Analysis of the ictal
electro­encephalogram has found that, in general, more efficacious modes of stimulation cause more powerful, stereotypical
seizures, followed by post-ictal suppression.
Contemporary theories for the mechanism of action are concerned with: enhanced serotonergic and noradrenergic activity
coupled with reduced cholinergic activity in the brain; mood
stabilization through the anticonvulsant effects of ECT; and
the enhanced expression of neuroprotective proteins, such as
brain-derived neurotrophic factor, which putatively antagonize
the neurotoxic effects of stress on the brain. Interest in the last
theory is likely to grow because it has recently been shown that
the animal model of ECT is a rapid and effective inducer of neuro­
genesis in the hippocampus of non-human primates as well as
rodents.4

Keywords adverse effects; bipolar affective disorder; continuation
­treatment; contraindications; electroconvulsive therapy (ECT); electrode
placement; indications; major depression; mania; mood disorders;
­outcome

Artificially induced convulsions have been used for more than
300 years in attempts to treat severe mental illnesses. Cerletti
and Bini first used electricity as the means of induction in Rome
in 1938, and this turned out to be a much more reliable method
than, for example, the administration of camphor. Electroconvulsive therapy (ECT) is the electrical induction of a generalized
tonic–clonic convulsion with the aim of treating an abnormal
mental state or neurological disorder; efficacious treatment
requires a series of inductions given two or three times a week.
Advances in pharmacotherapy have undoubtedly led to a reduction in the usage of ECT over the past ten years. The annual
rate of ECT usage in the UK is now approximately one patient in
10,000 of the general population.1

Indications for ECT
A comprehensive systematic review concluded that real ECT was
substantially more efficacious than sham ECT (standardized effect
size 0.91) and more efficacious than pharmacotherapy (standardized effect size 0.80) in the short-term treatment of depressive ­
illness.5 The salutary finding of a complementary review of patients’
perspectives on ECT found that at least one-third reported significant memory loss after treatment.6 This was the major reason that
the then National Institute for Clinical Excellence (NICE) later recommended that ECT be used only to achieve rapid and short-term
improvement of severe symptoms after an adequate trial of other
treatment options has proved ineffective and/or when the condition is considered to be potentially life-threatening.7 This guidance
is not consistent with the extant recommendations from the Royal
College of Psychiatrists, which identified wider indications for ECT
(see below). The ECT Handbook includes guidance for prescribers to help them accommodate their practice to the discrepancy
between the College and NICE.8

Mode of action
Seminal studies on the mode of action of ECT were originally
taken to show that the convulsion itself was the essential therapeutic ingredient. In 1987, the results of a study were published
which showed that the induction of a series of generalized
tonic–clonic convulsions (average length 47 seconds) was no
more efficacious than sham ECT.2 The dose of electricity was
only just sufficient to induce a convulsion (‘threshold stimulation’), and the electrode placement was unilateral. Later work
showed that unilateral electrode placement with a dose six times

Depressive illness
The College recommendations regarding the place of ECT in the
treatment of major depressive disorder are shown in Table 1.

Allan IF Scott BSc MD MPhil MBA FRCPsych is Consultant Psychiatrist at
the Royal Edinburgh Hospital and Honorary Senior Lecturer at the
University of Edinburgh, UK. He is the psychiatrist with clinical and
administrative responsibility for the ECT clinic in Edinburgh, and editor
of The ECT Handbook (second edition). Conflicts of interest: none
declared.

PSYCHIATRY 8:4

Treatment-resistant illness: the traditional opinion is that a prior
history of failure to recover with antidepressant drug treatment
has no bearing on the likelihood of recovery with ECT. Open
prospective studies of representative samples of contemporary
135

© 2009 Elsevier Ltd. All rights reserved.

Nevertheless. There are depressed patients who do not recover with high-dose unilateral ECT but who subsequently recover with bilateral ECT. Treatment can be continued until the No absolute medical contraindications to ECT exist. i. and some require 12 or more treatments to achieve full clinical remission. The average total number of twice-weekly bilateral treatments in the UK is approximately seven. the first four treatments may lead to an increase in the electrical dose or to a switch from unilateral to bilateral electrode treatment. 20058) Table 2 The selection of ECT may be affected by • patient choice • previous experience of ineffective and/or intolerable medical treatment • previous recovery with ECT • increased intracranial pressure • recent cerebral infarction • severe cardiovascular or pulmonary disease • aneurysms or vascular malformations that might be suscept­ ible to rupture with increased blood pressure. It is important to emphasize that the probability of recovery with ECT still extends to patients who are ill despite vigorous antidepressant drug treatment supplemented by augmentation strategies such as co-prescription of lithium carbonate.11 The most important decision will be the selection of either unilateral or bilateral electrode placement.11 the other did not. Contraindications Number: it is not possible to predict reliably the total number of treatments that an individual patient will require. however. Co-existing medical conditions that increase the risk of ECT include: PSYCHIATRY 8:4 136 © 2009 Elsevier Ltd.12 These studies were consistent in that there was no suggestion that treatment resistance to either selective serotonin reuptake inhibitors or monoamine oxidase inhibitors had any relationship with the likelihood of recovery. the lack of consensus concerns whether or not treatment resistance to tricyclic (and similar) antidepressant drugs and to lithium carbonate augmentation predict a reduced likelihood of recovery with ECT. and this may require discussion with a suitably experienced anaesthetist and/or physician. Bipolar disorder The College recommendations about the place of ECT in the treatment of patients with mania are shown in Table 2. The treatment of co-existing medical conditions should be optimized before elective treatment. There have been two open multicentre studies in the USA: one found that treatment resistance reduced the likelihood of recovery. • ECT may be considered for severe mania associated with: ○ life-threatening physical exhaustion ○ treatment-resistance. debate about the impact of treatment resistance specifically on the outcome in unipolar non-psychotic major depression. for example. • Selection of ECT may be affected by: ○ patient choice ○ previous experience of ineffective and/or intolerable medical treatment ○ previous recovery with ECT. the College has advocated the initial prescription of a unilateral placement. a lack of satisfactory improvement over.or third-line treatment Depressive illness that has not been treated adequately by antidepressant treatment. appropriate prescription requires an adequate assessment of the relative risks and benefits of treatment.Physical treatment Indications for ECT in major depression Place of ECT in the treatment of mania Potential treatment of choice Severe depressive illness. More frequent treatment carries the risk of more pronounced cognitive adverse effects. Electrode placement A comparison of unilateral and bilateral electrode placement is given in Table 3. . when the illness is associated with: • attempted suicide • strong suicidal ideas or plans • life-threatening illness because of refusal of food or fluids • The treatment of choice for mania is a mood-stabilizing drug plus an antipsychotic drug.10 There is. mania that has not responded to the treatment of choice. 20058) Table 1 The prescribing cycle patients continue to support this opinion.9. but some patients improve dramatically after fewer. where social recovery has not been achieved. (Adapted from Royal College of Psychiatrists Special Committee on ECT. If the urgency of response is not critical. Clinical monitoring of depressive symptoms and possible adverse cognitive effects is necessary throughout the course of treatment.e. Frequency and number of treatments Frequency: twice-weekly bilateral treatment brings about the same final outcome as treatment three times per week. and then the frequency and total number of treatments. but perhaps with a slower rate of improvement. Treatment to be considered Severe depressive illness associated with: • stupor • marked psychomotor retardation • depressive delusions and/or hallucinations Second. All rights reserved. (Adapted from Royal College of Psychiatrists Special Committee on ECT.

8 ◆ Outcome The later randomized controlled trial mentioned above found that. A later open multicentre study of 253 patients with unipolar major depression used the same definition of recovery. but not all. that the patient has been treated with a series of generalized tonic–clonic convulsions that were induced with a dose of electricity in excess of the seizure threshold as described in the clinic’s treatment protocol. in major depression. NICE did not recommend ECT as a continuation or prophylactic treatment in the absence of relevant evidence from controlled trials.000 treatments. The gap in episodic memory (anterograde amnesia) is inevitable after each individual treatment and is an understandable direct consequence of the post-ictal state. 60% of patients recovered with highdose unilateral ECT and 65% recovered with high-dose bilateral ECT. the loss of memory for autobiographical or public events in the weeks and perhaps months before admission to hospital. one week after treatment. On the other hand. Bipolar patients may be precipitated into hypomania.7 The College anticipated that some patients with recurrent and otherwise treatment-resistant illnesses might still give valid informed consent for the use of ECT itself as a continuation treatment. 20058) Table 3 patient recovers or two consecutive treatments bring no further clinical improvement. Approximately 5% of patients PSYCHIATRY 8:4 References 1 Scott AI.e.Physical treatment complain of confusion or dizziness at some point. so it may be helpful to warn patients that ECT can lead to gaps in memory during the course of treatment. Patients can be reassured that retrograde amnesia can occur in the absence of any impairment of new learning. It is necessary to ensure. if a relative telephones to enquire after a patient on the morning after treatment.13 Adverse effects The commonest spontaneous complaint after an individual treatment is of muscle pain (8%). 137 © 2009 Elsevier Ltd. What is more alarming is if patients come to realize that they have also experienced retrograde amnesia. plus a final maximum score of no more than 10. of the memories may return over the next 6 months. if definite but slight clinical improvement is observed early on. 75% of patients recovered with moderate-dose bilateral ECT. it may be reasonable to extend the course to 12 treatments. certain types of memory problem are commonly associated with treatment. . Nevertheless. including the co-prescription of lithium carbonate. For example. Patients suffering major depression with psychotic features experienced earlier and more robust clinical improvement.14 Prospective brain imaging studies have failed to find any structural changes in the brain after repeated treatment with ECT. Br J Psychiatry 2008. i. All rights reserved. If no clinical improvement at all is seen. about one-third of patients will complain spontaneously of headache and 20% of memory problems. Over a course of treatment. The calculated mortality rate is less than 2 deaths per 100. 192: 476. ECT itself may be considered as continuation treatment. 50% above seizure threshold 45 min >10% (Adapted from Royal College of Psychiatrists Special Committee on ECT. Only 1–2% of patients experience nausea or vomiting. The risk may still exceed 50% over 12 months in spite of continuous treatment in patients who failed to recover with drug treatment before ECT. Some critics of ECT have argued that the positive outcomes reported in controlled trials are not achieved in routine clinical practice. Decreased usage of electroconvulsive therapy: implications. Aware of this gap in the evidence. Patients who have recovered successfully with an acute course of treatment can sustain remission with ECT given every 2–4 weeks. This may not be noticed until the end of the course of treatment when patients start to spend time away from the ward.3 Recovery was defined as a reduction of at least 60% in the score on the Hamilton Depression Rating Scale. and that some. and vigorous continuation of antidepressant drug treatment is therefore indicated for at least 6 months after successful recovery. it is quite likely that the patient will have no recollection of this the next day. The management of patients who do not improve early in the course of treatment is more difficult. first. Most relapses occur in the first 4 months. The ECT Handbook includes further guidance on this use of ECT. Prolonged seizures or post-ictal delirium are rare consequences of seizure induction. Continuation treatment There has always been a substantial risk of relapse if patients are untreated after a successful course of ECT. Augmentation strategies may be appropriate. it may be reasonable to discontinue the course after about six treatments. When vigorous continuation of psychotropic drug treatment has previously proved ineffective or intolerable. Fraser T. Comparison of unilateral and bilateral ECT Placement Seizure threshold Efficacy of threshold stimulation Optimal initial stimulation Average time to re-orientation after treatment Risk of prolonged disorientation Unilateral Bilateral Temporo-parietal over non-dominant hemisphere Lower Similar to sham ECT 4–6 times seizure threshold 20 min Bi-temporal <2% Advice to patients Higher Moderate Sufferers can be reassured that there is no credible evidence that ECT causes any kind of brain damage.

2005. Haskett RF. J Clin Psychiatry 2007. Coplan JD. 57: 425–34. 7 National Institute for Health and Clinical Excellence. J Clin Psychopharmacol 2004. 2nd edn. Lisanby SH. et al. Antidepressant–induced neurogenesis in the hippocampus of adult nonhuman primates. Kevan IM. 9 van den Broek WW. Effect of antidepressant medication resistance on short-term response to electroconvulsive therapy. double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Decina P. et al.) American Psychiatric Association. 17: 244–53. Resistance to antidepressant medications and short-term clinical response to ECT. Prudic J. et al. 326: 1363–65. 5 UK ECT Review Group. Effects of electrode placement on the efficacy of titrated. et al. The practice of electroconvulsive therapy: recommendations for treatment. Antidepressant medication treatment failure does not predict lower remission with ECT for major depressive disorder: a report from the Consortium for Research in Electroconvulsive Therapy. training and privileging. 144: 1449–55. London: Royal College of Psychiatrists. et al. 24: 400–3. 2 Sackeim HA. Does ECT alter brain structure? Am J Psychiatry 1994. 2003 (accessed 30. J Affect Disord 2004. 2001. Am J Psychiatry 1996. Oxford: Oxford University Press. low dosage ECT. Mulsant B. 4 Perera TD. Lancet 2003. 11 Prudic J. 12 Rasmussen KG.) 138 © 2009 Elsevier Ltd. Leese M. Linnell R. A prospective. Patients’ perspectives on electroconvulsive therapy: systematic review. uk/TA059. 14 Devanand DP. The ECT handbook. (Guidance from the Task Force on ECT.nice. J Neurosci 2007. 27: 4894–901. 8 Royal College of Psychiatrists Special Committee on ECT. Mulder PGH. the APA equivalent of the College’s Special Committee on ECT. Electroconvulsive therapy. 6 Rose D. Arch Gen Psychiatry 2000. 13 Petrides G. et al. 3 Sackeim HA. et al. 153: 985–92. J ECT 2001. Electroconvulsive therapy (ECT). (A comprehensive textbook. ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. Knapp RG. 361: 799–808. Available from: http://www. BMJ 2003. All rights reserved. Husain MM. 68: 1701–6. Am J Psychiatry 1987. et al. . de Lely A. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and metaanalysis. et al. Dwork AJ. Devanand DP. randomized. Kanzler M. PSYCHIATRY 8:4 Further reading Abrams R. Electroconvulsive therapy in depressive illness that has not responded to drug treatment. Mueller M.org.Physical treatment 10 Husain S. 2nd edn. et al. 151: 957–70. Fink M. 4th edn. 2002. Hutchison ER.08). Washington: American Psychiatric Association.12. 86: 121–26. Wykes T.