When is electroconvulsive therapy (ECT) indicated?

Updated: Sep 24, 2019
  • Author: Mehul V Mankad, MD; Chief Editor: Dennis M Popeo, MD  more...
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Answer

Answer

ECT is indicated for selected patients with catatonia, major depressive disorder, bipolar disorder, schizophrenia, and other disorders.

Catatonia

Considered one of the most lethal psychiatric disorders, few treatments are currently available for the treatment of catatonia. No randomized controlled trials of ECT for the treatment of catatonia exist, likely due to the relative rarity and severity of the condition. Patients who have failed medical treatment with benzodiazepines still have at least an 80% likelihood of response to ECT. [20]  World Federation of Societies of Biological Psychiatry (WFSBP) clinical guidelines for the treatment of catatonia related to schizophrenia recommend the use of ECT upon failure of benzodiazepines. [21]

Major depressive disorder

ECT should be considered for patients in the acute phase of major depressive disorder who have a history of treatment resistance (as defined by greater than two antidepressant trials), high degree of symptom severity, or who have psychotic symptoms. [22]  ECT is more effective in patients with psychotic features accompanying their major depressive episode than nonpsychotic patients. [5]  ECT may also be the treatment of choice for patients in whom treatment response is urgently needed, such as patients who are acutely suicidal or those who are refusing food and are nutritionally compromised. These considerations of symptom severity should be given regardless of the number of prior antidepressant medication failures. [22]

ECT may be useful in patients with major depressive disorder for whom medication or psychotherapy has not been effective in maintaining stability during the continuation phase. [23, 22]  ECT should be considered in patients whose condition has failed to respond to medication trials, individuals who have not tolerated indicated medications, or those who have previously shown a response to ECT. [22]  ECT also should be considered in patients with melancholic and atypical depression. [24, 25]

Bipolar disorder

ECT may be considered for patients in the depressive phase, manic phase, or mixed phase of bipolar disorder, [26, 27, 28]  Response rates of depressive symptoms in bipolar patients are similar to unipolar patients, and response rates exceed 70% for the manic phase of the illness. [29] ECT also is a potential treatment for those experiencing severe mania or depression during pregnancy, particularly in the first trimester when teratogenic risks from traditional mood stabilizing medications may be greater. [28, 30] ECT may be efficacious in patients with rapid cycling bipolar disorder. [31] Mania resulting from ECT is uncommon. [1]  

Schizophrenia

ECT can be considered an adjunctive biological treatment for schizophrenia in combination with first- or second-generation antipsychotics. While treatment with clozapine should be considered in cases of treatment-resistant schizophrenia, the use of ECT may benefit patients already receiving antipsychotic medication. [32]  In those patients who are already receiving clozapine and experiencing breakthrough symptoms of psychosis, the addition of ECT can have adjunctive benefits. [33]

ECT may be particularly beneficial if mood symptoms (depression, mania, or suicidal ideation) are present. [34]

Comorbid disorders

ECT is not recommended for the treatment of obsessive-compulsive disorder (OCD) but may be considered for treating comorbid disorders such as major depressive disorder, mania, and schizophrenia in patients with OCD. [35]  The efficacy of ECT in the treatment of core symptoms of posttraumatic stress disorder (PTSD) is inconclusive. [36]

Other disorders and indications

ECT has been effective in the treatment of neuroleptic malignant syndrome, [37] depression associated with Parkinson disease, [38, 39]  and particular cases of delirium, [40] It has also been effective in treating patients with intellectual disabilities who have treatment-resistant mood or psychotic disorders. [41]


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