Chapter 2: 2.1. - Indications for Use of ECT - Psychiatric Disorders

Written by Juli Lawrence

2.4.1. Psychiatric disorders. Besides the major diagnostic indications discussed above, the evidence for the efficacy of ECT in the treatment of other psychiatric disorders is limited. As noted earlier, major diagnostic indications for ECT may coexist with other conditions, and practitioners should not be dissuaded by the presence of secondary diagnoses from recommending, ECT when it is otherwise indicated, e.g., a major depressive episode in a patient with a pre-existing anxiety disorder. However, there is no evidence of beneficial effects in patients with Axis II disorders or most other Axis I disorders who do not also have one of the major diagnostic indications for ECT. Although there are case reports of favorable outcome in some selective conditions, evidence for efficacy is limited. For example, some patients with medication-resistant obsessive compulsive disorder may show improvement with ECT (Gruber 1971; Dubois 1984; Mellman and Gorman 1984; Janike et al. 1987; Khanna et al. 1988; Maletzky et al. 1994). However, there have been no controlled studies in this disorder, and the longevity of the beneficial effect is uncertain.

2.4.2. Mental disorders due to medical conditions. Severe affective and psychotic conditions secondary to medical and neurological disorders, as well as certain types of deliria, may be responsive to ECT. The use of ECT in such conditions is rare and should be reserved for patients who are resistant or intolerant to more standard medical treatments, or who require an urgent response. Prior to ECT, attention should be given to the evaluation of the underlying etiology of the medical disorder. It is largely of historical interest that ECT has been reported to be of benefit in conditions such as alcoholic delirium (Dudley and Williams 1972; Kramp and Bolwig 1981), toxic delirium secondary to phencyclidine (PCP) (Rosen et al. 1984; Dinwiddie et al. 1988), and in mental syndromes due to enteric fevers (Breakey and Kala 1977; O'Toole and Dyck 1977; Hafeiz 1987), head injury (Kant et al. 1995), and other causes (Stromgren 1997). ECT has been effective in mental syndromes secondary to lupus erythematosus (Guze 1967; Allen and Pitts 1978; Douglas and Schwartz 1982; Mac and Pardo 1983). Catatonia may-be secondary to a variety of medical conditions and is usually responsive to ECT (Fricchione et al. 1990; Rummans and Bassingthwaighte 1991; Bush et al. 1996).

When evaluating potential secondary mental syndromes, it is important to recognize that cognitive impairment may be a manifestation of major depressive disorder. Indeed, many patients with major depression have cognitive deficits (Sackeim and Steif 1988). There is a subgroup of patients with severe cognitive impairment that resolves with treatment of the major depression. This condition has been termed "pseudodementia" (Caine, 1981). Occasionally, the cognitive impairment may be sufficiently severe to mask the presence of affective symptoms. When such patients have been treated with ECT, recovery has often been dramatic (Allen 1982; McAllister and Price 1982: Grunhaus et al. 1983: Burke et al. 1985: Bulbena and Berrios 1986; O'Shea et al. 1987; Fink 1989). It should be noted, however, that the presence of pre-existing neurological impairment or disorder increases the risks for ECT-induced delirium and for more severe and persistent amnestic effects (Figiel et al. 1990; Krystal and Coffey, 1997). Furthermore, among patients with major depression without known neurological disease, the extent of preECT cognitive impairment also appears to predict the severity of amnesia at follow-up. Thus, while patients with baseline impairment thought to be secondary to the depressive episode may show improved global cognitive function at follow-up, they may also be subject to greater retrograde amnesia (Sobin et al. 1995).

2.4.3. Medical disorders. The physiological effects associated with ECT may result in therapeutic benefit in certain medical disorders, independent of antidepressant, antimanic, and antipsychotic actions. Since effective alternative treatments are usually available for these medical disorders. ECT should be reserved for use on a secondary basis.

There is now considerable experience in the use of ECT in patient's with Parkinson's disease (see Rasmussen and Abrams 1991; Kellner et al. 1994 for reviews). Independent of effects on psychiatric symptoms, ECT commonly results in general improvement in motor function (Lebensohn and Jenkins 1975; Dysken et al. 1976; Ananth et al. 1979; Atre-Vaidya and Jampala 1988; Roth et al. 1988; Stem 1991; Jeanneau, 1993; Pridmore and Pollard 1996). Patients with the "on-off" phenomenon, in particular, may show considerable improvement (Balldin et al. 1980 198 1; Ward et al. 1980; Andersen et al. 1987). However, the beneficial effects of ECT on the motor symptoms of Parkinson's disease are highly variable in duration. Particularly in patients who are resistant or intolerant to standard pharmacotherapy, there is preliminary evidence that continuation or maintenance ECT may be helpful in prolonging the therapeutic effects (Pridmore and Pollard 1996).

Neuroleptic malignant syndrome (NMS) is a medical condition that has been repeatedly shown to improve following ECT (Pearlman 1986; Hermle and Oepen 1986; Pope et al. 1986-1 Kellam 1987; Addonizio and Susman 1987; Casey 1987; Hermesh et al. 1987; Weiner and Coffey 1987; Davis et al. 1991). ECT is usually considered in such patients after autonomic stability has been achieved, and should not be used without discontinuation of neuroleptic medications. Since the presentation of NMS restricts the pharmacological options for treatment of the psychiatric condition, ECT may have the advantage of being effective for both the manifestations of NMS and the psychiatric disorder.

ECT has marked anticonvulsant properties (Sackeim et al. 1983; Post et al. 1986) and its use as an anticonvulsant in patients with seizure disorders has been reported since the 1940s (Kalinowsky and Kennedy 1943; Caplan 1945, 1946; Sackeim et al. 1983; Schnur et al. 1989). ECT may be of value in patients with intractable epilepsy or status epilepticus unresponsive to pharmacological treatment (Dubovsky 1986; Hsiao et al. 1987; Griesener et al. 1997; Krystal and Coffey 1997).

RECOMMENDATIONS

2.1. General Statement

Referrals for ECT are based upon a combination of factors, including, the patient's diagnosis, type and severity of symptoms, treatment history, consideration of the anticipated risks and benefits of ECT and alternative treatment options, and patient preference. There are no diagnoses which should automatically lead to treatment with ECT. In most cases ECT is used following treatment failure on psychotropic medications (see Section 2.2.2), although specific criteria exist for the use of ECT as a first-line treatment (see Section 2.2.1).