Section 4.10

Electroconvulsive Treatment

General Description

Electroconvulsive therapy(ECT) is a safe and effective treatment of patients with major depressive disorders, mania, and other serious mental disorders. Developed in 1934, electroconvulsive therapy has experienced wide fluctuations in popularity throughout the world. Many international psychiatric experts consider ECT as an underused treatment. Currently, about 50,000 to 100,000 patients receive ECT annually in the United States.

Electroconvulsive therapy involves the administration of electricity to the brain with the production of seizures. The mechanism of action of the ECT is unclear with most theories focusing on changes in the neurotransmitter receptors and changes in the second-messenger systems. Virtually, every neurotransmitter system is affected by ECT. ECT affects include a down regulation of the B-adrenergic receptors, the same receptor change with occurs with antidepressants. The effects on serotonergic receptors are still being debated.

Indications

Electroconvulsive therapy is generally used in the following cases:

    • when a patient has failed to respond to optimal pharmacotherapy,
    • when pharmacotherapy is contraindicated for medical reasons,
    • when ECT has previously been effective for a patient and is the patient?s preferred treatment modality, and
    • when a sustained clinical emergency exists requiring a rapid clinical response. One or more of these indications must be present to justify electroconvulsive therapy.

    Clinical trials have demonstrated the efficacy of electroconvulsive therapy in treating major depressive disorders (with or without psychotic features), manic episodes (with or without psychotic features), schizophrenia, schizoaffective disorder, some other functional psychoses, and obsessive-compulsive disorder. In addition, clinical trials have demonstrated the efficacy of maintenance electroconvulsive therapy, especially in recurrent affective disorders.

    The majority of requests for electroconvulsive therapy authorization should be reserved for patients with severe affective disorders. Request for ECT authorization is also appropriate for some carefully selected patients with mania, schizophrenia, schizoaffective disorder, other functional psychoses, and obsessive-compulsive disorder.

    For consideration of electroconvulsive therapy, the psychiatrist should conduct a thorough re-evaluation of the biopsychosocial components of the patient?s disorder. This re-evaluation should include the patient?s psychiatric condition, diagnosis, treatment-to-date, and response to treatment. Past medication trials and medical history should be carefully and completely reviewed - to assess if the patient has indeed received an adequate trial of medication treatment.

    The possibility of any personality disorder which may complicate the patient?s treatment should be addressed and/or resolved prior to requesting electroconvulsive therapy. Social relationships which may be contributing to the patient?s psychiatric condition should be examined. Significant people in the patient?s life should be interviewed and involved in the treatment. All possible interventions in the patient?s social life should be attempted before requesting electroconvulsive therapy.

    It should be remembered that the medical necessity for electroconvulsive therapy does not imply the medical necessity for inpatient care. Determination of the medical necessity for electroconvulsive therapy and the determination of the medical necessity for an inpatient level of care are independent of each other. ECT may be an appropriate therapy option for both inpatients and outpatients - if the patient meets the criteria for electroconvulsive therapy.

    In cases where a patient meets medical necessity for electroconvulsive therapy but does not require inpatient treatment, the Orange County Health Care Agency will need to make a determination of the most appropriate setting for the administration of the electroconvulsive treatment. That decision will be made by clinical administration at the Health Care Agency, usually involving one of the QI psychiatrists.

    Criteria

    The criteria that follow should take into account the need for a full re-evaluation of the overall treatment of the patient. Before requesting ECT, the psychiatrist must make certain that the pharmacotherapy and psychotherapy have been optimized. The psychiatrist must feel justified in stating that the patient is treatment-refractory with no other options.

    For electroconvulsive therapy to be determined to be medically necessary: (1) the patient must have an ECT-responsive condition, (2) the patient must be receiving optimal psychosocial and physical-medical care, and (3) the patient must be in a clinical situation that justifies electroconvulsive therapy.

    The patient must have had a thorough medical work-up within the 3 previous months, including determination of serum thyroid-stimulating hormone and any known physical-medical contributors to the patient?s mental disorder. If the patient has not received a thorough medical work-up within the last 3 months, then this medical work-up must be part of the pre-ECT evaluation.

    The patient must be receiving optimal therapeutic techniques to treat any of the following conditions, if they are present: (1) any DSM-IV personality disorder, (2) any significant relationship problems with family members or significant others, and (3) any substance abuse or dependence. These complicating factors should be addressed before ECT, as studies showed reduced efficacy of ECT if these factors persist after the electroconvulsive trial.

    The clinical circumstances that justify electroconvulsive therapy should include: (1) the patient has a history of responding only minimally to at least 2-3 adequate trials of medication, and (2) the patient appears more likely to respond to ECT than to another medication trial. To substantiate the first clinical circumstance, the psychiatrist should document prior medications, prior dose levels, length of time for the various treatments, any augmenting agents, extent of clinical improvement, any adverse reactions, and reasons for discontinuing the medication.

    There is an additional clinical circumstance that justifies electroconvulsive therapy: e.g., if the patient is in a state of sustained clinical emergency with an imminent danger of seriously injuring himself/herself through either (1) an active intent or plan to harm himself/herself or (2) an inability to assure his/her own physical safety due to a psychotic or physically incapacitating affective state. In this circumstance, it is believed that ECT offers a substantially faster treatment response than any trial of medication.

    Contraindications

    When the medical necessity criteria are satisfied, electroconvulsive therapy may be offered to a wide range of patients, including children, adolescents, adults and the elderly. For children and adolescents, the ECT psychiatrist must meet certain legal requirements and the ECT psychiatrist should have special expertise with this younger age group. For the elderly, the dosages of anticholinergic, anesthetic and relaxant drugs may need modifications, but the procedure can still have high efficacy and it may be less risky than pharmacotherapy.

    There are not any absolute contraindication for electroconvulsive therapy. But there are situations that are associated with substantial risk. These situations include space occupying cerebral lesions, conditions with increased intracranial pressure, recent myocardial infarction with unstable cardiac function, recent intracerebral hemorrhage, unstable vascular aneurysm or malformation, retinal detachment, or pheochromocytoma.

    Another situation that creates substantial risk is an anesthesia risk level of 4 or 5. This risk must be assessed by the anesthesiologist involved with the administration of the electroconvulsive therapy; and this risk must be determined by using the rating scale of the American Society of Anesthesiologists. Patients with levels of 4 or 5 should not receive electroconvulsive therapy - unless the anesthesiologist decides that this patient is the rare exception.

    Electroconvulsive therapy can be used in all three trimesters of pregnancy. Teratogenic risks (up to 8 weeks of gestation) should be noted during the informed consent process. Noninvasive monitoring of fetal heart rate during each ECT treatment session is encouraged when gestation is over 10 weeks. Additional monitoring and the presence of an obstetrician may be indicated in high risk cases or when the patient is close to term.

    Adverse Effects

    Electroconvulsive therapy is associated with some potential adverse effects. These adverse effects may include cognitive dysfunction, cardiovascular dysfunction, prolonged apnea, prolonged seizures, treatment emergent mania, and adverse subjective reactions by the patient for their families.

    The psychiatrist should obtain a baseline cognitive assessment, using one of the standard tools. For any cognitive dysfunction, modifications in electroconvulsive treatment can be initiated. The ECT psychiatrist can change from bilateral to unilateral right electrode placement, decrease the intensity of electrical stimulation, increase time interval between treatments, alter the dosage of medications, and terminate the treatment course, if necessary.

    Drug Interactions

    During the course of electroconvulsive therapy, agents that increase morbidity or decrease the efficacy of ECT should be discontinued or decreased. These drugs would include benzodiazepines, most other sedative hypnotics, anticonvulsants, lidocaine and its analogues, reserpine, lithium, and theophylline.

    In general, it is advisable to discontinue psychotropic agents prior to ECT, although this should not prevent the institution of medication treatments on a timely basis. For example, low to moderate doses of neuroleptics may be helpful early in the treatment course for patients with psychosis. For MAO-inhibitors, an appreciable drug free period is necessary prior to ECT.