What are the indications for Electroconvulsive Therapy (ECT)?

Indications for Electroconvulsive Therapy (ECT)

ECT is indicated for severe psychiatric conditions including major depression, bipolar disorder, schizophrenia with affective features, catatonia, and neuroleptic malignant syndrome, with response rates of 70-80% and remission rates of 40-50% in Major Depressive Disorder. 1

Primary Indications

ECT should be considered when a patient meets all three of the following criteria:

1. Diagnosis:

   • Severe, persistent major depression (with or without psychotic features)
   • Mania (with or without psychotic features)
   • Schizoaffective disorder
   • Schizophrenia (especially with prominent affective symptoms)
   • Catatonia (regardless of underlying cause)
   • Neuroleptic malignant syndrome 2, 1

2. Severity of Symptoms:

   • Symptoms must be severe, persistent, and significantly disabling
   • Life-threatening symptoms such as:
     • Refusal to eat or drink
     • Severe suicidality
     • Uncontrollable mania
     • Florid psychosis 2

3. Lack of Treatment Response:

   • Failure to respond to at least two adequate trials of appropriate psychopharmacological agents
   • Each medication trial should have adequate duration and dosage 2

Special Considerations for Earlier Use of ECT

ECT may be considered earlier in the treatment algorithm when:

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

Evidence of Effectiveness

ECT has demonstrated significant effectiveness in treatment-resistant populations:

• Response rates of 70-80% and remission rates of 40-50% in Major Depressive Disorder 1
• In severely treatment-resistant patients, studies show 65.8% response rate and 53.3% remission rate, even after failing an average of 5.4 different pharmacological treatments 3
• ECT is associated with reduced suicide risk in hospitalized patients with major depressive disorder (HR, 0.72; 95% CI, 0.52-0.99), particularly in patients:
  • With psychotic features (HR, 0.20)
  • Aged 45 years or older 4

Special Populations

Adolescents

• Same indications as adults but with more stringent criteria for treatment resistance
• Requires comprehensive documentation of previous treatment failures
• Necessitates thorough assessment of cognitive function before, during, and after treatment 1

Older Adults

• Often show enhanced response rates to ECT
• Experience improved quality of life following treatment 1
• Particularly beneficial for those aged 65 years or older in reducing suicide risk (HR, 0.30) 4

Patients with Comorbidities

• Mental retardation is not a contraindication for ECT
• Personality disorders do not contraindicate ECT in patients with severe mood disorders
• Seizure disorders are not contraindications; ECT may actually reduce seizure frequency in some cases 2

Contraindications

There are no absolute contraindications to ECT except raised intracranial pressure 5. Relative contraindications include:

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

Cognitive Effects Considerations

Recent meta-analyses indicate:

• ECT may cause deterioration in overall cognitive function and learning capabilities
• Executive function and processing speed may actually improve following ECT
• Memory, attention, language, and spatial perception typically show no significant long-term detriments 2
• The Electroconvulsive Therapy Cognitive Assessment (ECCA) has superior sensitivity compared to MMSE or MoCA in detecting cognitive changes 2

Pre-ECT Evaluation Requirements

Before initiating ECT, a comprehensive evaluation must include:

• Detailed psychiatric evaluation with clinical interview and collateral information
• Documentation of target symptoms using reliable rating instruments
• Thorough review of past pharmacological and psychological treatments
• Complete physical examination and appropriate laboratory investigations
• Assessment of cognitive function 2

ECT remains one of the most effective treatments for severe psychiatric conditions, particularly when other treatments have failed or when rapid response is needed in life-threatening situations.