Electroconvulsive Therapy Background Paper - Conditions for Which ECT Is Used

Written by RESEARCH-ABLE, INC.

Conditions for Which ECT Is Used

Because beneficial psychopharmacological drugs are easier to administer, less expensive, and not as controversial as ECT, such interventions are usually attempted prior to employing ECT. ECT is generally considered only for persons with severe or psychotic forms of affective disorders (depression or bipolar illness) who either have failed to respond to other therapies or are considered to be at imminent risk of suicide. Since an antidepressant may not become fully effective for several weeks after treatment begins, the rapidity of symptom relief associated with ECT may make it the treatment of choice for people who cannot safely wait for alternative treatments (such as people who are suicidal). (15) ECT can make the patient accessible to the efficacious effects of medications and psychotherapy. (16) Clinicians also report that ECT can reduce the duration of episodes of mania and major depression, (17) and if used promptly, may help to shorten hospital stays of people with recurrent major depression. (18)

The Agency for Health Care Policy and Research, in a recent clinical practice guideline, (19) suggests ECT is appropriately used for selected patients with serious depressive disorders.

"It is a first-line option for patients suffering from severe or psychotic forms of major depressive disorder, whose symptoms are intense, prolonged, and associated with neurovegetative symptoms and/or marked functional impairment, especially if these patients have failed to respond fully to several adequate trials of medication. Electroconvulsive therapy may also be considered for patients who do not respond to other therapies, those at imminent risk of suicide or complications, and those with medical conditions precluding the use of medications...."

"However, ECT should be considered cautiously and used only after consultation with a psychiatrist, because ECT:

• Has not been tested in milder forms of illness.
• Is costly when it entails hospitalization.
• Has specific and significant side effects (e.g., short-term retrograde and anterograde amnesia).
• Includes the risks of general anesthesia.
• Carries substantial social stigma.
• Can be contraindicated when certain other medical conditions are present.
• Usually requires prophylaxis with antidepressant medication, even if a complete, acute phase response to ECT is attained."

No general agreement exists within the medical community regarding the utility of ECT in the treatment of schizophrenia. Although a number of clinical studies suggest ECT is effective in treating people with schizophrenia, (20) they are not definitive.

Further research is also needed to determine whether ECT reinforces the effects of neuroleptic drugs. Clinicians find most ECT patients benefit from the use of supportive drug and/or talk therapy once ECT has alleviated the worst depressive or other symptoms. Recent scientific reports suggest major mood disorders among pregnant women can safely be treated with ECT if appropriate steps are taken to decrease risks to both mother and child. (21,22)

Importance of Patient Consent to Treatment

In the wake of the ongoing controversy surrounding ECT, the medical community has become increasingly sensitive to the importance of obtaining informed voluntary consent from patients before initiating treatment. State laws and regulations, as well as professional guidelines, (23) spell out in detail, the nature of such consent. They suggest or require that the medical provider educate the patient and his/her family using written and audio-visual materials as well as verbal explanations, before the patient signs a consent form. (24) Required or suggested consent forms generally specify the following kinds of information:

1. the nature of the treatment;
2. the likely benefits and possible risks of treatment;
3. the number and frequency of treatments to be undertaken;
4. alternative remedies; and
5. stipulations that patients retain the right to withdraw consent at any time during the treatment process.

In the case of an individual whose cognitive functioning and/or judgment may be impaired by psychiatric illness, it may be difficult to be certain of fully informed voluntary consent (see the discussion of legal aspects in Section IV below).

The 1985 NIMH Consensus Development Conference on ECT (25) commented on the issue of informed and voluntary consent:

"When the physician has determined clinical indications justify the administration of ECT, the law requires, and medical ethics demand, the patient's freedom to accept or refuse the treatment be fully honored. An ongoing consultative process should take place. In this process, the physician must make clear to the patient the nature of the options available and the fact the patient is entitled to choose among these options."