Psychotic depression, electroconvulsive

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. 

Exercise (regular aerobic and weight training at least three times a week) / The use of electroconvulsive therapy for severe mania or mixed episodes, psychotic depression, or rapid cycling is still considered the best... 

It is well established that monotherapy with various antidepressants or mood stabilizers is relatively ineffective (i.e., they are necessary but not sufficient) for treating mood disorders with associated psychosis. Thus, psychotically depressed patients are best managed with a combination of antipsychotic-antidepressant or with electroconvulsive therapy. Although antipsychotics have a more rapid onset of action than lithium in an acute manic episode, we are unaware of clinical trials that examine the differential effect of antipsychotics or lithium for nonpsychotic versus psychotic mania. This topic is discussed further in... 

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). 

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. 

Electroconvulsive treatment conversely, was quite effective in certain groups of patients, such as those with psychotic depressive disorders. However, early methods of administration were fraught with dangerous complications and side effects, and ECT was used on a widespread basis, indiscriminately. Many patients were treated with it inappropriately and did not respond. (As shall be discussed later, in recent years significant advances have been made in ECT, and it now affords a highly effective, safe treatment for selected types of patients.)... 

When symptoms of major depression and psychosis coexist, medication treatment is always warranted. (Often hospitalization, ECT, or both may also be necessary.) Psychotically depressed patients do not respond to psychotherapy alone, and they represent a very high suicide risk when actively psychotic. It has been firmly documented that treatment with antidepressants alone is not very effective (only 25 percent). Likewise, treatment with antipsychotics alone produce disappointing results (35 percent effective). However, combined antidepressant-antipsychotic treatment is significantly more effective (60 to 70 percent). Electroconvulsive treatment is really the gold standard in the treatment of psychotic mood disorders (90 percent effective). (See chapters 14 and 17, on treatment with antidepressants and antipsychotics, respectively.)... 

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. 

The psychotic disorders include schizophrenia, the manic phase of bipolar (manic-depressive) illness, acute idiopathic psychotic illnesses, and other conditions marked by severe agitation. All exhibit major disturbances in reasoning, often with delusions and hallucinations. Several classes of drugs are effective for symptomatic treatment. Antipsychotic agents also are useful alternatives to electroconvulsive therapy (ECT) in severe depression with psychotic features, and sometimes are used in the management of patients with psychotic disorders associated with delirium or dementia or induced by other agents (e.g., stimulants or L-DOPA). 

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. 

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