The Practice of Electroconvulsive Therapy - Electroconvulsive Therapy

Written by Juli Lawrence

The evaluation may include either bedside assessment of orientation and memory and/or more formal test measures. It should include determination of orientation in the three spheres (person, place, and time), as well as immediate memory for newly learned material (e.g., reporting back a list of three to six words) and retention over a brief interval (e.g., reporting back the list 5-10 minutes later). Remote recall might likewise be assessed by determining memory for events in the recent and distant past (e.g., events associated with the hospitalization, memory for personal details: address, phone number, etc.).

Formal testing instruments provide quantitative measures for tracking change. To assess global cognitive functioning, an instrument such as the Mini-Mental State exam (Folstein et al. 1975) may be used. To track orientation and immediate and delayed memory, subtests of the Russell revision of the Weschler Memory Scale could be used (Russell 1988). To formally assess remote memory, tests of recall or recognition of famous people or events can be used (Butters and Albert 1982; Squire 1986). When cognitive status is assessed, the patient's perception of cognitive changes should also be ascertained. This may be done by informally inquiring whether the patient has noticed any changes in his/her abilities to concentrate (e.g., to follow a television program or a magazine article) or to remember visitors, events of the day, or recall of more remote events. Patient perception of memory functioning may also be examined using a quantitative instrument (Squire et al. 1979).

In the event that there has been a substantial deterioration in orientation or memory functioning during the ECT course that has not resolved by discharge from the hospital, a plan should be made for post-ECT follow-up of cognitive status. Most commonly there is marked recovery in cognitive functioning within days of the end of the ECT course (Steif et al. 1986) and patients should be reassured that this will likely be the case. The plan should include a description of when follow-up assessment would be desirable, as well as the specific domains of cognitive function to be assessed. It may be prudent in such cases to conduct additional evaluations, e.g., neurological and electroencephalographic examinations, and if abnormal to repeat until there is resolution.

It should be kept in mind that the cognitive evaluation procedures suggested here provide only gross measures of cognitive status. Furthermore, interpretation of changes in cognitive status may be subject to a number of difficulties. Psychiatric patients frequently have cognitive impairments prior to receiving ECT and a therapeutic response may therefore be associated with improvement in some cognitive domains (Sackeim and Steif 1988). However, while some patients show improved scores relative to their pre-ECT baseline, they still may not have fully returned to their baseline level of cognitive functioning (Steif et al. 1986). This discrepancy may be a basis for complaints about lingering cognitive deficits. In addition, the procedures suggested here only sample limited aspects of cognitive functioning, for example, deliberate learning and retention of information. Patients may also have deficits in incidental learning. Likewise, the suggested procedures concentrate on verbal memory, although both right unilateral and bilateral ECT produce deficits in memory for nonverbal material (Squire 1986).

Other adverse effects. During the ECT course, any onset of new risk factors, or significant worsening of those present at pre-ECT, should be evaluated prior to the next treatment. When such developments alter the risks of administering ECT, the consentor should he informed and the results of this discussion documented. Patient complaints about ECT should be considered adverse effects. The attending physician and/or a member of the ECT treatment team should discuss these complaints with the patient, attempt to determine their source, and ascertain whether corrective measures are indicated.

13. Management of Patient's Post-ECT Course

Continuation therapy, which is defined as the extension of somatic therapy over the 6-month period following induction of a remission in the index episode of mental illness, has become the rule in contemporary psychiatric practice. Exceptions may include patients who are intolerant to such treatment and possibly those with either an absence of prior episodes or a history of extremely long periods of remission (although compelling evidence for the latter is lacking). Unless residual adverse effects necessitate a delay, continuation therapy should be instituted as soon as possible after remission induction, since the risk of relapse is especially high during the first month. Some practitioners believe that the onset of symptoms of impending relapse in patients who are ECT responders may represent an indication for institution of a short series of ECT treatments for a combination of therapeutic and prophylactic purposes, although controlled studies are not vet available to substantiate this practice.

Continuation pharmacotherapy. A course of ECT is usually completed over a 2- to 4-week period. Standard practice, based in part on earlier studies (Seager and Bird 1962; Imlah et al. 1965; Kay et al. 1970), and in part on the parallel between ECT and psychotropic drug therapies, suggests continuation of unipolar depressed patients with antidepressant agents (with the possible addition of an antipsychotic drug in cases of psychotic depression), bipolar depressives with antidepressant and/or antimanic medications; and manics with antimanic and possibly antipsychotic agents. For the most part, dosages are maintained at 50%-100% of the clinically effective dose range for acute treatment, with adjustment up or down depending upon response. Still, the role of continuation therapy with psychotropic drugs after a course of ECT is undergoing assessment, and our recommendations should be considered provisional. Disappointment with high relapse rates, especially in patients with psychotic depression and in those who are medication resistant during the index episode (Sackeim et al., 1990), compels reconsideration of present practice, including a renewed interest in continuation ECT (Fink 1987b).

Continuation ECT. While psychotropic continuation therapy is the prevailing practice. few studies document the efficacy of such use after a course of ECT, and some recent studies report high relapse rates even in patients complying with such regimens (Spiker et al. 1985; Aronson et al. 1987, 1988a, 1988b; Sackeim et al., in press). These high relapse rates have led some practitioners to recommend continuation ECT for selected cases. Recent retrospective reviews of this experience find surprisingly low relapse rates among patients so treated, although controlled studies are not yet available (Kramer 1987; Decina et al. 1987; Clarke et al. 1989; Loo et al. 1988; Matzen et al. 1988; Thornton et al. 1988). Because continuation ECT appears to represent a viable form of continuation management of patients following completion of a successful course of ECT, facilities are encouraged to offer this modality as a treatment option. Patients referred for continuation ECT should meet all of the following criteria: 1) history of recurrent illness that is acutely responsive to ECT; 2) either refractoriness or intolerance to pharmacotherapy alone or a patient preference.