Is Electroconvulsive Therapy (ECT) effective?

Effectiveness of Electroconvulsive Therapy (ECT)

ECT is highly effective for severe psychiatric conditions, with response rates of 70-80% and remission rates of 40-50% in major depressive disorder, even in medication-resistant cases. 1

Indications for ECT

ECT demonstrates significant efficacy in treating:

• Major depressive disorder - particularly severe or medication-resistant cases
• Bipolar disorder - both severe mania and treatment-resistant bipolar depression
• Schizophrenia - especially with prominent affective features or catatonia
• Catatonia - regardless of underlying cause
• Neuroleptic malignant syndrome
• Schizoaffective disorder 1

Patient Selection Criteria

ECT should be considered when:

1. Severe and persistent symptoms that are significantly disabling or potentially life-threatening:

   • Refusal to eat or drink
   • Severe suicidal ideation or behavior
   • Uncontrollable mania
   • Florid psychosis 1

2. After failure of standard treatments:

   • At least two adequate trials of antidepressants for major depression
   • Failed trials of mood stabilizers alone or with antipsychotics for bipolar disorder
   • Inadequate response to antipsychotics for schizophrenia 1

3. Earlier consideration is warranted when:

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

Efficacy in Special Populations

• Adolescents: ECT can be effective with similar indications as adults, but requires more stringent criteria for treatment resistance and comprehensive cognitive assessment 2, 1
• Older adults: Often show enhanced response rates to ECT and experience improved quality of life 1
• Patients with neurological conditions: ECT may be safely administered after assessment of neurological risk, even in patients with cerebral lesions, seizure disorders, or history of craniotomy 2
• Patients with mental retardation: Benefits similar to those without mental retardation, without additional risk of side effects 2

Common Pitfalls and Caveats

1. Relapse prevention is crucial:

   • High relapse rates are a significant challenge, especially since ECT is usually discontinued once effective
   • Continuation/maintenance ECT may be necessary for some patients to prevent relapse 3

2. Treatment resistance affects outcomes:

   • While historical response rates for ECT were quoted at ≥90%, response rates in medication-resistant depression may be closer to 60% 3

3. No absolute contraindications:

   • Relative contraindications include tumors of the central nervous system with elevated cerebrospinal fluid pressure, active chest infections, and recent myocardial infarction 1

4. Cognitive effects:

   • Modern ECT techniques have significantly reduced cognitive side effects
   • Unilateral electrode placement using brief pulse current minimizes post-treatment confusion and memory impairment 4

Augmentation Strategies

Combining ECT with depression-specific psychotherapy represents a promising strategy to enhance outcomes and reduce relapse rates, though more research is needed in this area 5.

ECT remains an important treatment option that should not be overlooked in psychiatric practice, particularly for severe and treatment-resistant conditions where it can significantly improve morbidity, mortality, and quality of life 6.