Electroconvulsive therapy ECT

Anticholinergic drugs (TCAs, low-potency phenothiazines, clozapine, olanzapine all may increase cognitive impairments) 

Bupropion, clozapine, low-potency phenothiazines, maprotiline, TCAs (all have the capacity to significantly decrease seizure threshold and may cause prolonged seizure activity) 

Lithium (may interfere with pseudocholinesterase (the enzyme that degrades succinylcholine) and cause prolonged muscle paralysis) 

Monamine oxidase inhibitors (MAOIs) (may impair blood pressure management and might also inhibit pseudocholinesterase) 

TeCAs ( ) - those drugs that block the reuptake of norepinephrine at the transporter site Vanlafaxine ( ) 

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Electroconvulsive therapy (ECT) is a highly efficacious treatment for MDD. The response rate is about 80% to 90% and even exceeds 50% for patients who have failed pharmacotherapy.16,17 ECT may be particularly beneficial for MDD that is complicated by psychotic features, severe suicidality, refusal to eat, pregnancy, or contraindication/non-response to pharmacotherapy.16,17 ECT is typically a very safe treatment alternative, but various cautions do exist, and the chief side effects are confusion and memory impairment.16... 

Electroconvulsive therapy (ECT) is the application of prescribed electrical impulses to the brain for the treatment of severe depression, mixed states, psychotic depression, and treatment-refractory mania in patients who are at high risk of suicide. It also may be used in pregnant women who cannot take carbamazepine, lithium, or divalproex. 

Electroconvulsive therapy (ECT) is used for severe mania or depression during pregnancy and for mixed episodes prior to treatment, anticonvulsants, lithium, and benzodiazepines should be tapered off to maximize therapy and minimize adverse effects. 

Shock Therapy. The early 20th century saw the development of the first effective biological treatments for depression, the shock therapies. The first shock treatments used injection of horse serum or insulin. A major advance in treatment occurred with the advent of electroconvulsive therapy (ECT) in 1934. Although initially used to treat schizophrenia, ECT was soon found to be highly effective for other psychiatric disorders including depression and mania. ECT remained the primary biological psychiatric treatment until the widespread release of psychiatric medications in the 1950s. 

Electroconvulsive Therapy (ECT). Introduced in the mid-1930s, ECT was initially used to treat schizophrenia (for which it is not effective) but was later found to be very effective in the treatment of major depression and mania. It gained widespread use and was the primary biological psychiatric treatment until the introduction of newer psychiatric medications in the 1950s. 

Finally, when depressive symptoms persist after treatment with both a mood stabilizer and an antidepressant has been maximized, other treatment alternatives remain. These include the use of electroconvulsive therapy (ECT) or the addition... 

Shock Therapy. Insulin coma treatments were used in the early 1900s but offered no tangible improvement. Electroconvulsive therapy (ECT) arose in the 1930s and 1940s and was the hrst treatment to provide some relief from psychosis. However, its effects are only temporary and it proved too costly for continuous use. ECT continues to have some use for life-threatening catatonia, but it is mainly used to treat refractory depression or bipolar disorder. 

For very severe cases of depression, electroconvulsive therapy (ECT) can be tried. However, you must remember that demented patients are especially sensitive to the adverse memory effects of ECT. 

Repetitive TMS, unlike electroconvulsive therapy (ECT), uses sub-convulsive stimuli to treat depression. Compared to ECT, TMS has a potential to target specific brain regions and to stimulate brain areas thought to be primarily involved in depression while sparing areas like the hippocampus, thereby reducing the probability of cognitive side effects. However, the therapeutic efficacy of TMS as a treatment for depression is, unlike ECT, modest. Most TMS studies use high-frequency, fast stimulation (> 10 Hz) over the left dorsolateral prefrontal cortex, an area which has been... 

Electroconvulsive therapy (ECT) There are no clinical studies establishing the benefit of the combined use of ECT and SSRIs. Rare prolonged seizure in patients on fluoxetine has occurred. 

A second part consists of two chapters covering other somatic interventions, including complementary, alternative, and naturopathic medicine approaches (such as St. John s wort), as well as more aggressive treatments less commonly used in children and adolescents, such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS). 

Electroconvulsive therapy (ECT) has been described in the treatment of refractory mania in two prepubertal children (Hill et al., 1997). Rey and Walter (1997) have also summarized the literature on juvenile ECT, including its use in mania in adolescents (also see Chapter 30 in this volume). 

Electroconvulsive therapy [ECT] is mostly used for severe depression. Elowever, a balanced, extensive review of the literature by Sackeim s group (see Nobler et ah, Chapter 10, in this volume] reveals not only the remarkable potency and safety of this politically controversial mode of treatment, but also the multiplicity of its biological influence and impact on a diversified gamut of brain functions. ECT is probably also effective in acute manic states and might be viewed as a mood stabilizer. Whether or not maintenance ECT acts as a mood stabilizer is still unknown. It might be viewed as an antidepressant with a broad stabilizing effect. 

Electroconvulsive therapy [ECT] is one of the oldest somatic treatments in psychiatry. The emergence of the field of psychopharmacology in the 1960s eclipsed advancement in ECT practice and research. To some extent, the pendulum has swung back in the past 15 years, as there has been intensive rediscovery of the basic science of ECT and an increase in its clinical use. Contemporary research has reexamined clinical issues, such as indications for treatment, response prediction, and relapse prevention, given the changing nature of psychiatric treatment and referral patterns. At the same time, more sophisticated approaches to treatment... 

Electroconvulsive therapy (ECT) is an established and effective treatment of depression and some forms of schizophrenia. ECT is the treatment of choice in several types of depression (W. Z. Potter and Rudorfer 1993), especially severe depression (American Psychiatric Association Task Force on Electroconvulsive Therapy 1990 W. Z. Potter et al. 1991). The mechanism by which ECT exerts its antidepressant effect is still unknown. Studies of pharmacologically as well as of electrically induced convulsions suggest that the convulsion is a necessary condition for ECT s therapeutic effects (Cerletti and Bird 1938 Lerer 1987 Lerer et al. 1984). However, there is no satisfactory explanation for the clinical efficacy of convulsions. 

Several small, open-label studies have supported TCA/antipsychotic combinations in the treatment of PMD. Minter and Mandel [1979) studied 54 inpatients with PMD who were treated openly with either TCAs alone, TCAs and antipsychotic combination, antipsychotics alone, or electroconvulsive therapy [ECT] in treatment failures. Although only 3 of 11 patients treated with TCAs alone responded, 16 of 16 patients treated with the combination of a TCA and an antipsychotic responded. Interestingly, 14 of 15 patients treated with antipsychotic drugs alone also responded, which is contrary to findings in other studies [Spiker et al. 1985). Several other open-label studies have confirmed the utility of the combination treatment for PMD [Charney and Nelson 1981 Frances et al. 1981), but few controlled studies have been completed. 

The literature regarding the role of electroconvulsive therapy (ECT) in OCD has been conflicting and confusing. Several case reports reported efficacy in individual patients (Mellman and Gorman 1992). In a study of eight patients with OCD who received ECT, only one had a good and sustained antiobsessional response (B. Guttmacher, personal communication, 1993). 

Coffey CE, Lucke J, Weiner RD, et al Seizure threshold in electroconvulsive therapy, 1 initial seizure threshold. Biol Psychiatry 37 713-720, 1995a Coffey CE, Lucke J, Weiner RD, et al Seizure threshold in electroconvulsive therapy (ECT), 11 the anticonvulsant effect of ECT. Biol Psychiatry 37 777-788, 1995b Cohen MR, Niska RW Localized right hemisphere dysfunction and recurrent mania. Am J Psychiatry 137 847-848, 1980... 

Swartz CM, Lewis RK Theophylline reversal of electroconvulsive therapy (ECT) seizure inhibition. Psycho somatic s 32 47-51, 1991... 

Tremor and akathisia are less common and can be managed with dose reduction or the addition of a P-blocker such as propranolol (10-40 mg). There are isolated case reports of SSRl-related dystonia and increasing reports of SSRl-related exacerbation of Parkinson s disease (Di Rocco et al. 1998 Linazasoro 2000). The advisability of SSRl use in depressed patients with Parkinson s disease remains to be determined. Bupropion and electroconvulsive therapy (ECT) may be reasonable alternatives for these patients. 

All modalities, from electroconvulsive therapy (ECT) to psychotherapy, can be incorporated into our approach when empirical data support their utility. When sufficient data are lacking, we offer suggestions based on our cumulative clinical and research experience. 

When the results from several studies are converted into similar units, a simple inspection of a graph or table readily reveals which studies have different outcomes from the majority. Such discrepancies can also be examined by a variety of statistical indices. For example, one can calculate a statistical index of homogeneity, remove the most discrepant study, and recalculate, revealing that all but one study is homogenous. If two studies are discrepant, one could remove both and again reexamine the indices of homogeneity, and so on. For an example, we summarize the relative efficacy of unilateral nondominant versus bilateral electrode placement for the administration of electroconvulsive therapy (ECT). Here, 10 studies had one result, and two others a different outcome (see Table 8-10 and Table 8-11, in Chapter 8). 

Combined risperidone and electroconvulsive therapy (ECT) produced a remarkable improvement in one patient s refractory depression, but it also caused a return of prior TD symptoms (106). When clozapine was added to the ECT-risperidone regimen and risperidone was tapered gradually, the patient s TD signs and symptoms remitted, and she responded well to combined ECT and clozapine. 

Treatment Implications. A review of response rates found that only 35% of patients with psychotic depression responded to treatment with a tricyclic antidepressant alone versus 67% of patients with nonpsychotic depression (Table 6-6) (13). Yet these patients have a better response to electroconvulsive therapy (ECT) (14). These patients have also been found to respond to combined treatment with an antidepresssant and an antipsychotic in comparison with either an antidepressant or antipsychotic alone (15). Despite these data, one study found that less than 50% of patients with psychotic depression referred to an ECT service had been treated with an antipsychotic and only 15% had received a daily dose equivalent to 200 mg or more or chlorpromazine ( 16). 

Somatic therapies have had a long and at times dubious history in the treatment of mental disorders. Clearly, electroconvulsive therapy (ECT) has stood the test of time but has also been plagued by problems in terms of misuse, underuse, a complicated administration process, cognitive adverse effects, and a negative public image. Even so, ECT remains the most effective treatment for some of the most severely ill, medication-refractory, or medication-intolerant patients, often proving to be lifesaving (1). 

FIG. 8-1. The role of electroconvulsive therapy (ECT) and possibly of other somatic therapies in the treatment of psychiatric disorders. Adapted from Martis and Janicak, 2000. 

Consider alternative therapies when feasible, such as antipsychotics or electroconvulsive therapy (ECT) modified for pregnancy. 

Sedation is uncommon and instead many patients will find that these drugs may impair sleep, which is why the dose is best taken in the morning. There is also little effect on psychomotor function. Occasional patients have a small reduction in heart rate but otherwise effects on the cardiovascular system are rare. Epileptic convulsions can occur but are rare and much less common than with tricyclic antidepressants. There is some evidence for potentiation of electroconvulsive therapy (ECT)-induced seizures. Sexual dysfunction is reported, principally delayed ejaculation and anorgasmia. 

Failure to respond to a variety of antidepressants, singly or in combination, is the key factor indicating consideration of electroconvulsive therapy (ECT). This is the only therapeutic agent for the treatment of depression that is rapid in onset and can... 

Finally, some patients may need a completely different type of treatment, such as electroconvulsive therapy (ECT). ECT is often viewed as a treatment of last resort, but it should not be withheld from patients with this disorder who cannot be helped by drug therapy. For patients with psychotic depression, ECT may be a treatment of first choice. 

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