Chapter 2: 2.1. - Indications for Use of ECT - When Should a Referral for ECT Be Made?

Written by Juli Lawrence

2.2. When Should a Referral for ECT Be Made?

2.2.1. Primary Use of ECT

Situations where ECT may be used prior to a trial of psychotropic medication include, but are not limited to, any of the following:

a) need for rapid, definitive response due to the severity of a psychiatric or medical condition

b) the risks of other treatments outweigh the risks of ECT

c) history of poor medication response or good ECT response in one or more previous episodes of illness

d) patient preference

2.2.2. Secondary Use of ECT

In other situations, a trial of an alternative therapy should be considered prior to referral for ECT. Subsequent referral for ECT should be based on at least one of the following:

a) treatment resistance (taking into account issues such as choice of medication, dosage and duration of trial, and compliance)

b) intolerance or adverse effects with pharmacotherapy which are deemed less likely or less severe with ECT

c) deterioration of the patient's psychiatric or medical condition creating a need for a rapid, definitive response

2.3. Major Diagnostic Indications

Diagnoses for which either compelling data support the efficacy of ECT or a strong consensus exists in the field supporting such use:

2.3.1. Major Depression

a) ECT is an effective treatment for all subtypes of unipolar major depression, including major depression single episode (296.2x) and major depression, recurrent (296.3x) (American Psychiatric Association 1994).

b) ECT is an effective treatment for all subtypes of bipolar major depression, including bipolar disorder; depressed (296.5x); bipolar disorder mixed (296.6x); and bipolar disorder not otherwise specified (296.70).

2.3.2. Mania

ECT is an effective treatment for all subtypes of mania, including bipolar disorder, mania (296.4x); bipolar disorder, mixed (296.6x), and bipolar disorder, not otherwise specified (296.70).

2.3.3. Schizophrenia and Related Disorders

a) ECT is an effective treatment for psychotic exacerbations in patients with schizophrenia in any of the following situations:

1) when duration of illness from initial onset is short

2) when psychotic symptoms in the present episode have an abrupt or recent onset

3) catatonia (295.2x) or

4) when there is a history of a favorable response to ECT

b) ECT is effective in related psychotic disorders, notably schizophreniform disorder (295.40) and schizoaffective disorder (295.70). ECT may also be useful in patients with psychotic disorders not otherwise specified (298-90) when the clinical features are similar to those of other major diagnostic indications.

2.4. Other Diagnostic Indications

There are other diagnoses for which the efficacy data for ECT are only suggestive or where only- a partial consensus exists in the field supporting its use. In such cases, ECT should be recommended only after standard treatment alternatives have been considered as a primary intervention. The existence of such disorders, however, should not deter the use of ECT for treatment of patients who also have a concurrent major diagnostic indication.

2.4.1. Psychiatric Disorders

Although ECT has sometimes been of assistance in the treatment of psychiatric disorders other than those described above (Major Diagnostic Indications, Section 2.3), such use is not adequately substantiated and should be carefully justified in the clinical record on a case-by-case basis.

2.4.2. Psychiatric Disorders Due to Medical Conditions

ECT may be effective in the management of severe secondary affective and psychotic conditions displaying symptomatology similar to primary psychiatric diagnoses, including catatonic states.

There is some evidence that ECT may be effective in treating deliria of various etiologies, including toxic and metabolic.

2.4.3. Medical Disorders

The neurobiological effects of ECT may be of benefit in a small number of medical disorders.

Such conditions include:

a) Parkinson's disease (particularly with the "on-off ' phenomenon b) neuroleptic malignant syndrome

c) intractable seizure disorder

next: Chapter 5. Adverse Effects
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