Electroconvulsive therapy refractory

Electroconvulsive therapy may be useful in drug-refractory cases... 

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. 

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. 

Depression refractory to other antidepressants or electroconvulsive therapy PO Initially, 10 mg 3 times/day. May increase to 60 mg/day. 

Electroconvulsive therapy is one of the most efficacious treatments for adults with nonresistant (70% response) and resistant MDD (50% response) (APA, 2000). Because of the invasiveness of this treatment, however, it remains the treatment of choice only for the most severe, incapacitating forms of resistant depression. No studies have been carried out among adolescents, but anecdotal reports have suggested that adolescents with refractory depression may respond to ECT without significant side effects (Rey and Walter, 1997). Approximately 60% of adult patients treated successfully with ECT tend to relapse after 6 months (APA, 2000). Therefore, they must also receive maintenance treatment with antidepressants and sometimes maintenance ECT. There are no reports of use of maintenance ECT in adolescents. 

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). 

Lithium has been proven effective for acute and prophylactic treatment of both manic and depressive episodes in patients with bipolar illness (American Psychiatric Association 2002). However, patients with rapid-cycling bipolar disorder (i.e., patients who experience four or more mood disorder episodes per year) have been reported to respond less well to lithium treatment (Dunner and Fieve 1974 Prien et al. 1984 Wehr et al. 1988). Lithium is also effective in preventing future depressive episodes in patients with recurrent unipolar depressive disorder (American Psychiatric Association 2002) and as an adjunct to antidepressant therapy in depressed patients whose illness is partially refractory to treatment with antidepressants alone (discussed in Chapter 2). Furthermore, hthium may be useful in maintaining remission of depressive disorders after electroconvulsive therapy (Coppen et al. 1981 Sackeim et al. 2001). Lithium also has been used effectively in some cases of aggression and behavioral dyscontrol. 

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. 

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). 

Electroconvulsive therapy is especially useful when rapid onset of clinical effect is desired and when patients are refractory to a number of antidepressant drugs. It is also very helpful in psychotic and bipolar depression and in postpartum psychosis. If the mechanism of the therapeutic action of ECT could be unraveled, it might lead to a new antidepressant drug capable of rapid onset of antidepressant effects or with special value for refractory patients. Until then, ECT will remain a valuable member of the therapeutic armamentarium for depression. 

In addition, electroconvulsive therapy is available for patients with severe refractory depression. The mechanism by which this treatment alleviates depression is controversial it may increase the ability of the nerves in the central nervous system (CNS) to respond to noradrenaline and serotonin (5-HT). 

Electroconvulsive therapy (ECT) is probably the most effective treatment for major depressive disorder (MDD) with psychotic features, with average response rates of 70-90%, compared with only about 40% for regular antidepressant medications. The response rates for MDD without psychosis are comparable between regular medications and ECT (about 70-75%). ECT is usually given to patients whose condition is refractory to or who are intolerant of antidepressant medication. 

Rasmussen KG, Shirlene M et al. Electroconvulsive therapy and newer modalities for the treatment of medication refractory illness. Mayo Clin Proc 2002 77 552-556. 

For patients who experience a breakthrough episode, the medication dose should first be optimized. When first-line medications at optimal dose fail to control symptoms, recommended treatment options include the addition of another first-line medication. Alternative treatment options include adding carbamazepine or oxcarbazepine in lieu of an additional first-line medication, adding an antipsychotic if not already prescribed, or changing from one antipsychotic to another. Of the antipsychotics, clozapine may be particularly effective for treatment of refractory illness. Electroconvulsive therapy (ECT) may also be considered for patients with severe or treatment-resistant illness. In addition, ECT is a potential treatment for patients with mixed episodes or for severe mania experienced during pregnancy. 

Electroconvulsive therapy remains the gold standard for the treatment of major depression and a variety of other psychiatric and neurologic disorders (97). Because of the effectiveness and resurgence of ECT, more patients are considered to be good candidates for this treatment option. Overall, these patients are medication refractory and elderly and, thus, are more sensitive to polypharmacy. Additionally, these patients tend to have more coexisting medical problems. 

Nyhuis PW, Gastpar M, Scherbaum N. Opiate treatment in depression refractory to antidepressants and electroconvulsive therapy. J Clin Psychopharmacol 2008 28 (5) 593-5. 

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