Chapter 2: 2.1. - Indications for Use of ECT - Mania - Indications for Use of ECT

Written by Juli Lawrence

2.3.2. Mania. Mania is a syndrome that, when fully expressed, is potentially life-threatening due to exhaustion, excitement, and violence. The early case literature first suggested that ECT is rapidly effective in mania (Smith et al. 1943; Impastato and Almansi 1943; Kino and Thorpe 1946). A series of retrospective studies comprised either naturalistic case series or comparisons of outcome with ECT to that with lithium carbonate or chlorpromazine (McCabe 1976; McCabe and Norris 1977; Thomas and Reddy 1982; Black et al. 1986; Alexander et al. 1988), Stromgren 1988; Mukherjee and Debsikdar 1992). This literature supported the efficacy of ECT in acute mania, and suggested equivalent or superior antimanic properties relative to lithium and chlorpromazine (see Mukherjee et al. 1994 for a review). There have been three prospective comparative studies of clinical outcome of ECT in acute mania. One study primarily compared ECT with lithium treatment (Small et al. 1988), another study compared ECT with combined treatment with lithium and haloperidol (Mukherjee et al. 1988. 1994), and in patients receiving neuroleptic treatment, one study compared real and sham ECT (Sikdar et al. 1994). While each of the prospective studies had small samples, the findings supported the conclusion that ECT was efficacious in acute mania, and likely resulted in superior short-term outcome than the comparison pharmacological conditions. In a review of the English language literature, Mukherjee et al. (1994) reported that ECT was associated with remission or marked clinical improvement in 80% of 589 patients with acute mania.

However, since the availability of lithium and anticonvulsant and antipsychotic medications, ECT has generally been reserved for patients with acute mania who do not respond to adequate pharmacological treatment. There is evidence from the retrospective and prospective studies that a substantial number of medication-resistant patients with mania benefit from ECT (McCabe 1976; Black et al. 1986; Mukherjee et al. 1988). For example, one of the prospective studies required that patients had failed an adequate trial of lithium and/or an antipsychotic medication prior to randomization to ECT or intensive pharmacotherapy. Clinical outcome was superior with ECT compared to combined treatment with lithium and haloperidol (Mukherjee et al. 1989). Nonetheless, the evidence suggests that, as with major depression, medication resistance predicts poorer response to ECT in acute mania (Mukherjee et al. 1994). While the majority of medication-resistant patients with acute mania respond to ECT, the response rate is lower than among patients in whom ECT is used as a first-line treatment.

The rare syndrome of manic delirium represents a primary indication for the use of ECT, as it is rapidly effective with a high margin of safety (Constant 1972; Heshe and Roeder 1975; Kramp and Bolwig 1981). In addition, manic patients who cycle rapidly may be particularly unresponsive to medications, and ECT may represent an effective alternative treatment (Berman and Wolpert 1987; Mosolov and Moshchevitin 1990; Vanelle et al. 1994).

Other than medication resistance, there have been few attempts to examine clinical features predictive of ECT response in acute mania. One study suggested that symptoms of anger, irritability and suspiciousness were associated with poorer ECT outcome. Overall severity of mania and degree of depression (mixed state) at preECT baseline were not related to ECT response (Schnur et al. 1992). In this respect, there may be some overlap between the clinical features predictive of response to ECT and lithium in acute mania (Goodwin and Jamison 1990).

2.3.3. Schizophrenia. Convulsive therapy was introduced as a treatment for schizophrenia (Fink 1979). Early in its use, it became evident that efficacy of ECT was superior in mood disorders than in schizophrenia. The introduction of effective antipsychotic medications markedly reduced the utilization of ECT in patients with schizophrenia. However, ECT remains an important treatment modality, particularly for patients with schizophrenia who do not respond to pharmacological treatment (Fink and Sackeim 1996). In the United States, schizophrenia and related conditions (schizophreniform and schizoaffective disorders) constitute the second most common diagnostic indication for ECT (Thompson and Blaine 1987; Thompson et al. 1994).

The earliest reports on the efficacy of ECT in patients with schizophrenia largely comprised uncontrolled case series (Guttmann et al. 1939; Ross and Malzberg 1939; Zeifert 1941; Kalinowsky 1943; Kalinowsky and Worthing 1943; Danziger and Kindwall 1946; Kino and Thorpe 1946; Kennedy and Anchel 1948; Miller et al. 1953), historical comparisons (Ellison and Hamilton 1949; Gottlieb and Huston 1951; Currier et al. 1952; Bond 1954) and comparisons of ECT with milieu therapy or psychotherapy (Goldfarb and Kieve 1945; McKinnon 1948; Palmer et al. 1951; Wolff 1955; Rachlin et al. 1956). These early reports lacked operational criteria for diagnosis and it is likely that the samples included mood-disorder patients, given the overinclusiveness of the diagnosis of schizophrenia in that era (Kendell 1971; Pope and Lipinski, 1978). Often, patient samples and outcome criteria were poorly characterized. Nonetheless, the early reports were enthusiastic regarding the efficacy of ECT, noting that a large proportion of patients with schizophrenia, typically on the order of 75%, showed remission or marked improvement (see Salzman, 1980; Small, 1985; Krueger and Sackeim 1995 for reviews). In this early work, it was also noted that ECT was considerably less effective in schizophrenic patients with insidious onset and long duration of illness (Cheney and Drewry, 1938: Ross and Malzberg 1939; Zeifert 1941; Chafetz 1943; Kalinowsky 1943; Lowinger and Huddleson 1945; Danziger and Kindwall 1946; Shoor and Adams 1950; Herzberg 1954). It was also suggested that schizophrenic patients commonly required particularly long courses of ECT to achieve full benefit (Kalinowsky, 1943; Baker et al. 1960a).

Seven trials have used a 'real vs. sham ECT' design to examine efficacy in patients with schizophrenia (Miller et al. 1953; Ulett et al. 1954, 1956; Brill et al. 1957, 1959a, 1959b, 1959c; Heath et al. 1964; Taylor and Fleminger 1980; Brandon et al. 1985; Abraham and Kulhara 1987; see Krueger and Sackeim 1995 for a review). The studies prior to 1980 failed to demonstrate a therapeutic advantage of real ECT relative to sham treatment (Miller et al. 1953; Brill et al. 1959a, 1959b, 1959c; Health et al. 1964). In contrast, the three more recent studies all found a substantial advantage for real ECT in short-term therapeutic outcome (Taylor and Fleminger 1980; Brandon et al. 1985; Abraham and Kulhara 1987). The factors that likely account for this discrepancy are the chronicity of the patients studied and the use of concomitant antipsychotic medication (Krueger and Sackeim 1995). The early studies focused mainly on patients with a chronic, unremitting course, while patients with acute exacerbations were more common in recent studies. All of the recent studies involved use of antipsychotic medications in both the real ECT and sham groups. As discussed below, there is evidence that the combination of ECT and antipsychotic medication is more effective in schizophrenia than either treatment alone.