What are the indications for Electroconvulsive Therapy (ECT) in psychiatry?

Indications for Electroconvulsive Therapy (ECT) in Psychiatry

ECT is indicated for severe psychiatric conditions that are treatment-resistant or require rapid intervention, primarily including major depression, bipolar disorder, schizophrenia with affective features, catatonia, and neuroleptic malignant syndrome. 1

Primary Diagnostic Indications

Major Mood Disorders

• Severe, persistent major depression with or without psychotic features
• Treatment-resistant depression that has failed at least two adequate antidepressant trials
• Severe mania with uncontrollable symptoms 1, 2

Schizophrenia and Related Disorders

• Schizophrenia with prominent affective symptoms
• Schizoaffective disorder
• Treatment-resistant schizophrenia, particularly when combined with pharmacotherapy 1, 3, 4

Emergency Psychiatric Conditions

• Catatonia (most responsive subtype to ECT)
• Neuroleptic malignant syndrome (NMS)
• Severe suicidality requiring rapid intervention 1, 5, 4

Severity Criteria for ECT Consideration

ECT should be considered when symptoms are:

• Severe and persistent
• Significantly disabling
• Potentially life-threatening, including:
  • Refusal to eat or drink
  • Severe suicidal ideation or behavior
  • Uncontrollable mania
  • Florid psychosis 1

Treatment Resistance Criteria

ECT is indicated after failure of standard treatments, specifically:

• Failure to respond to at least two adequate trials of appropriate medications
• Each medication trial should be of adequate dose and duration (8-10 weeks for antidepressants)
• For bipolar disorder, failed trials of mood stabilizers alone or in combination with antipsychotics 1

Expedited ECT Consideration

ECT may be considered earlier in the treatment algorithm when:

1. Patient cannot tolerate pharmacological treatments due to side effects
2. Patient is too incapacitated to take oral medications
3. Waiting for medication response may endanger the patient's life 1

Special Populations

Adolescents

For adolescents, ECT follows similar indications as adults but requires:

• More stringent criteria for treatment resistance
• Documentation of previous treatment failures
• Comprehensive assessment of cognitive function before, during, and after treatment 1

Maintenance ECT

Continuation/maintenance ECT is indicated for:

• Patients who achieved remission with acute ECT but are at high risk for relapse
• Administered at gradually increasing intervals during the 6-month period following remission 6

Contraindications

There are no absolute contraindications to ECT, though relative contraindications include:

• Tumors of the central nervous system with elevated cerebrospinal fluid pressure
• Active chest infections
• Recent myocardial infarction 1

Efficacy by Indication

• Major Depression: Highest efficacy with rapid response and remission rates
• Catatonia: Excellent response rates, often superior to medication alone
• Schizophrenia: Most effective when affective symptoms are prominent or combined with antipsychotics
• NMS: Effective when pharmacological treatments fail, particularly with prominent catatonic features 1, 5, 4, 7

Patient Selection Algorithm

1. Confirm diagnosis is among those responsive to ECT
2. Assess symptom severity - must be severe, persistent, and significantly disabling
3. Document treatment resistance - failure of at least two adequate medication trials
4. Evaluate for life-threatening features requiring rapid intervention
5. Consider patient factors that might influence ECT response (catatonia and affective symptoms predict better response)

ECT remains a highly effective treatment option that should not be considered a last resort but rather an important intervention for specific psychiatric conditions when properly indicated.