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Electroconvulsive Therapy: What the Internist Needs to Know

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Electroconvulsive Therapy: What the Internist Needs to Know REVIEW MAYUR PANDYA, DO LEOPOLDO POZUELO, MD DONALD MALONE, MD* CME Psychiatric Neuromodulation Center, Section Head, Consultation Liaison Psychiatry, Section Head, Adult Psychiatry, Medical CREDIT Cleveland Clinic Department of Psychiatry and Psychology, Director, Psychiatric Neuromodulation Center, Cleveland Clinic Cleveland Clinic Electroconvulsive therapy: What the internist needs to know ■ ABSTRACT LECTROCONVULSIVE THERAPY (ECT) has E an undeservedly bad reputation. This is Although electroconvulsive therapy (ECT) is widely used unfortunate. As currently performed, ECT is to treat a number of psychiatric disorders, many safe and is effective for treating a number of physicians are still unfamiliar with the procedure, its psychiatric disorders. For some patients, it is indications, and its contraindications. This article is an the only therapy that works. internist’s guide to ECT, with particular focus on how The following article outlines the indica- commonly prescribed medications and medical conditions tions for and contraindications to ECT and spe- affect ECT. cial considerations for patients referred for it. ■ KEY POINTS ■ TREATING MENTAL ILLNESS BY INDUCING SEIZURES ECT is safe and works rapidly, making it a primary therapy in situations requiring acute intervention. Another In 1927, Wagner-Jauregg won the Nobel Prize reason to consider ECT is a history of poor response to for curing patients with “dementia paralytica” medications or of adverse effects with medications. (tertiary syphilis) by infecting them with malaria. The concept that one illness could be treated by inducing another led von Meduna Although ECT was first used in patients with in 1934 to perform the first reported convul- schizophrenia, it is most often used today for mood sive therapy in psychiatry.1 disorders, including unipolar depression, bipolar Von Meduna, a neuropathologist, had depression, and acute mania. noted that patients with epilepsy had more glial cells than average, and patients with Before ECT is performed, patients require a medical schizophrenia had fewer. He had also seen evaluation to undergo anesthesia, and some may need data that few patients had both schizophrenia special consultation. and epilepsy (not true), and that when people with mental disorders suffered seizures, their Vagus nerve stimulation is the newest neuromodulatory mental condition often improved. He rea- technique to receive approval for adjunctive treatment of soned that if he could induce seizures in depression. Experimental treatments that show promise patients with schizophrenia by injecting cam- phor, their glial cells might increase, and their include deep brain stimulation and repetitive transcranial symptoms might improve. And in fact, in his magnetic stimulation. initial work, symptoms of schizophrenia improved partially to completely. In 1938, the Italians Bini and Cerletti performed the first documented electrical induction of seizures in humans.2 One year later, ECT was introduced to the United *Dr. Malone has obtained research funding from and is a consultant for Medtronic, Inc. States. Until effective antipsychotic drugs CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 • NUMBER 9 SEPTEMBER 2007 679 Downloaded from www.ccjm.org on October 1, 2021. For personal use only. All other uses require permission. ELECTROCONVULSIVE THERAPY PANDYA AND COLLEAGUES were developed in the 1950s, the only effec- resulting in interpersonal and financial dis- tive alternatives to ECT were insulin shock tress. According to the Global Burden of therapy and lobotomy, which was falling out Disease Study, depression ranks as the fourth- of favor. leading cause of disability worldwide.8 Initial In the early years, the lack of adequate therapies consist of drugs and psychotherapy, anesthesia or muscle relaxation resulted in alone or in combination. Patients with depres- fractures or dislocations, often with negative sion that is moderate to severe and resistant to recollection for the event. Lack of knowledge drug treatment may be referred for ECT, regarding the dose parameters of electrical which is often considered the gold standard stimulation led to more cognitive side effects. antidepressant treatment. Over the decades, the safety and efficacy Most patients should undergo an adequate of ECT have been improved and its indica- trial of oral drug therapy before being referred tions have been defined. Today, it is usually for ECT. The actual number of drugs that done with the patient under general anesthe- should be tried and for how long are deter- sia, and with muscle relaxants and cardiopul- mined on a case-by-case basis; in general, one monary monitoring, which have reduced its should try different classes of antidepressants complications. Nevertheless, ECT’s historical and various augmentation techniques before beginnings, combined with its negative por- turning to ECT. Poor response to medications trayal in the media,3 have left some patients or adverse effects with pharmacotherapy may fearful and hesitant to undergo ECT if they be reasons to consider ECT. need it. On the other hand, ECT’s safety and rapid efficacy make it a good primary treatment in How ECT works is unknown situations requiring acute intervention, such Although many mechanisms have been pro- as catatonia and psychiatric exacerbations posed, how ECT works remains unknown. An during pregnancy. attractive hypothesis to account for ECT’s All patients being considered for ECT effects on depression is that it alters serotonin should receive a general psychiatric evalua- ECT is far and dopamine activity.4,5 Changes in gamma- tion. The psychiatrist will then proceed with safer now aminobutyric acid (GABA) and noradrena- referral for ECT if appropriate and recom- line levels have also been reported.4,6 Most mend any necessary workup (discussed than in the past likely, the therapeutic effects of ECT are a below). result of a combination of neurotransmitter alterations. ■ ECT REQUIRES MEDICAL ASSESSMENT ■ MOST OFTEN USED Although no absolute contraindications to FOR MOOD DISORDERS ECT exist, several conditions are associated with an increased risk of complications and ECT was first used in patients with schizo- even death (see below). The cardiovascular, phrenia, and today, treatment-resistant psy- central nervous, and pulmonary systems carry chosis is still considered an appropriate indica- the highest risks from general anesthesia and tion for it. Today, however, ECT is most often the induction of generalized seizure activity. used for mood disorders, including unipolar In most routine cases, the patient under- depression, bipolar depression, and acute goes routine clearance for anesthesia, but spe- mania. cial considerations may necessitate consulta- The Diagnostic and Statistical Manual of tion with medical specialists such as a cardiol- Mental Disorders defines major depression as a ogist, neurologist, neurosurgeon, endocrinolo- constellation of symptoms, which may include gist, anesthesiologist, or dentist. All cases depressed mood, anhedonia, sleep distur- referred for ECT require analysis of the med- bance, psychomotor retardation or agitation, ical risks of treatment (discussed below). fatigue, guilt, poor concentration, and suici- The pre-ECT evaluation includes basic dality.7 The symptoms result in marked social tests such as a complete blood cell count, and occupational impairment, commonly serum electrolyte levels, renal function tests, 680 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 • NUMBER 9 SEPTEMBER 2007 Downloaded from www.ccjm.org on October 1, 2021. For personal use only. All other uses require permission. and electrocardiography. Neuroimaging, chest TABLE 1 radiography, and spine films are not routinely done unless clinically indicated. For example, Conditions requiring special consideration spine films may be necessary in some patients before electroconvulsive therapy who are elderly or who have osteoporosis. Conditions associated with autonomic sensitivity Compression fractures are not an absolute Clinically evident hyperthyroidism contraindication to ECT, but the physician Decompensated congestive heart failure performing ECT would want this information Elevated intracranial pressure so that he or she can make sure to provide Fragile aneurysm adequate paralysis. Careful attention should Narrow-angle or closed-angle glaucoma also be paid to the teeth, with dental consul- Pheochromocytoma tation obtained if needed. Recent myocardial infarction Before ECT, electrolyte levels should be Recent stroke stabilized and appropriate fluid status main- Severe valvular disease Significant arrhythmia tained. Uncontrolled hypertension Unstable angina ■ SOME ECT PATIENTS NEED SPECIAL CONSIDERATION Conditions associated with sensitivity to anesthesia Amyotrophic lateral sclerosis According to the American Psychiatric Genetic or acquired pseudocholinesterase deficiency Myasthenia gravis Association’s Task Force on Electroconvulsive Neuroleptic malignant syndrome 9 Therapy, patients with certain medical con- Porphyria ditions may require more extensive workup Pregnancy and consideration during ECT (TABLE 1). Conditions associated with cognitive sensitivity Patients with autonomic sensitivity Dementia Traumatic brain injury Seizure induction causes acute cardiopulmonary changes, including some initial parasympathetic bradycardia. This is followed by a sympathetic surge, causing transient tachycardia and hyper- and giving an antihypertensive agent (eg, tension. The sympathetic surge occurs only
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