What is the recommended treatment protocol for Electroconvulsive Therapy (ECT) in patients with severe, treatment-resistant major depression or bipolar disorder?

Recommended ECT Treatment Protocol for Severe, Treatment-Resistant Depression and Bipolar Disorder

Electroconvulsive therapy (ECT) should be administered with right unilateral electrode placement, brief pulse stimulation, three sessions per week for up to 6 weeks in patients with severe, treatment-resistant major depression or bipolar disorder who have failed at least two adequate medication trials. 1, 2

Patient Selection Criteria

Diagnostic Indications

• Severe, persistent major depression or mania (with or without psychotic features)
• Bipolar disorder
• Schizoaffective disorder
• Schizophrenia (particularly with prominent affective symptoms)
• Catatonia
• Neuroleptic malignant syndrome 3, 1

Severity Requirements

• Symptoms must be severe, persistent, and significantly disabling
• May include life-threatening symptoms such as:
  • Refusal to eat or drink
  • Severe suicidality
  • Uncontrollable mania
  • Florid psychosis 3, 1

Treatment Resistance Criteria

• For major depression: Failure to respond to at least two adequate trials of antidepressants (8-10 weeks at therapeutic doses)
• For bipolar disorder: Failure to respond to a mood stabilizer alone or in combination with a neuroleptic
• ECT may be considered earlier when:
  • Patient cannot tolerate pharmacological treatments
  • Patient is too incapacitated to take oral medications
  • Waiting for medication response may endanger the patient's life 3, 1

Pre-ECT Assessment

• Comprehensive psychiatric evaluation
• Documentation of target symptoms
• Thorough review of past treatments
• Complete physical examination
• Baseline cognitive assessment using Electroconvulsive Therapy Cognitive Assessment (ECCA) 1

ECT Administration Protocol

Electrode Placement

• Right unilateral (RUL) electrode placement is recommended as first-line
• RUL provides similar efficacy to bilateral placement with fewer cognitive side effects 4

Treatment Schedule

• Three sessions per week
• Course typically lasts up to 6 weeks
• Continue until remission is achieved or maximum of 12-14 treatments 1, 2

Stimulus Parameters

• Brief pulse stimulation
• Dose titration to determine seizure threshold at first session
• Subsequent treatments at 2.5-6 times seizure threshold for RUL placement 1, 2

Medication Management During ECT

• Consider tapering or discontinuing benzodiazepines and anticonvulsants that may interfere with seizure quality
• Lithium should typically be held 24-48 hours before ECT due to increased risk of delirium
• Antidepressants and antipsychotics can generally be continued
• Blood pressure medications should be administered the morning of treatment 5

Expected Outcomes

• Response rates: 70-80% in treatment-resistant depression
• Remission rates: 40-50% in major depressive disorder
• For bipolar depression specifically, response rates of approximately 80% can be expected 1, 6
• ECT is particularly effective in reducing suicide risk, with a 50% lower risk of suicide in the first year after discharge compared to hospitalized patients who did not receive ECT 3

Post-ECT Continuation Treatment

• Continuation ECT (C-ECT) should be considered for patients who:
  • Achieved remission with ECT but are at high risk of relapse
  • Failed to maintain remission with pharmacotherapy alone
• Maintenance schedule typically begins with weekly treatments, gradually extending to monthly 1
• Combination of maintenance ECT and pharmacotherapy may be more effective than either alone 4

Special Considerations

• Older adults often show enhanced response rates to ECT and experience improved quality of life 1
• Patients with comorbid obsessive-compulsive disorder or personality disorder may have lower response rates 6
• Raised intracranial pressure is an absolute contraindication
• Relative contraindications include CNS tumors with elevated CSF pressure, active chest infections, and recent myocardial infarction 1

Cognitive Side Effect Management

• Monitor cognitive function throughout treatment course using ECCA
• Consider extending time between treatments if cognitive side effects are problematic
• Cognitive side effects are typically transient, with most resolving within weeks to months after treatment completion 3, 1

ECT remains one of the most effective interventions for treatment-resistant depression and bipolar disorder, with higher efficacy than algorithm-based pharmacological approaches for these challenging conditions 7, 2.