Electroconvulsive Therapy: Clinical Indications
September 24, 2007
NYS Office of Mental Health
Efficacy for ECT has been established for mood disorders; schizophrenia and other psychotic disorders; and a small number of non-psychiatric medical conditions.
- Mood disorders
- Major Depressive Disorder (MDD)
ECT is the most effective and rapid acting treatment for unipolar depression; therefore for depressed persons at high risk for suicide, it can be the treatment of choice.
In MDD with Psychotic Features, antidepressants alone are less likely to provide amelioration of either mood or psychotic symptoms; thus, treatment should be with combined antidepressant and antipsychotic medications or ECT.
In depression in ambulatory patients where antidepressants from different classes have failed (e.g., a selective serotonin reuptake inhibitor or SSRI; a tricyclic antidepressant of TCA; and a monoamine oxidase inhibitor or MAOI), ECT should be discussed as an alternative to yet another medication trial.
Finally, there are co-morbid conditions which shift the risk/benefit ratio in favor of ECT over medication, including patients with depression who are elderly, physically debilitated, or pregnant,
- Bipolar Disorder
Acute depression in bipolar disorder does not generally respond (rapidly or adequately) to mood stabilizers, with the possible exception of lithium, lamotrigine and quetiapine, or to antidepressants (some of which can carry risk of precipitating the manic phase of the illness, called switching). Therefore, ECT should be considered for a patient with bipolar disorder in the depressive phase, particularly if unresponsive to even one medication trial of an antidepressant or mood stabilizer.
Unlike antidepressants, ECT does not lead to switching. In fact, ECT treats mania as well as depression, and, for mania either unresponsive to antidepressants or requiring rapid resolution due to potential danger to life or limb, ECT may be the treatment of choice for mania.
Finally, for persons with bipolar disorder and co-morbid medical conditions as well as some elderly patients, ECT may—contrary to common misconception—be a safer alternative than medication.
- Major Depressive Disorder (MDD)
The first use of ECT in psychiatry was in the treatment of schizophrenia, based on clinical observation that persons with epilepsy and schizophrenia often had an improvement in symptom severity following a spontaneous seizure.
Its efficacy in treating persons with schizophrenia and schizoaffective disorder has been well established, although its use decreased with the introduction of neuroleptics in the 1950s. ECT remains an effective treatment for persons with schizophrenia, and should be considered for persons with schizophrenia who have failed to respond to several antipsychotics, including clozapine, as well as in those whose co-morbid medical status makes ECT a safer option; in the case of persons with schizophrenia, this could include a history of neuroleptic malignant syndrome (NMS), particularly if this has occurred on more than one occasion.
- Non-psychiatric medical conditions
ECT, including maintenance ECT, has been helpful for patients with Parkinsonism where pharmacotherapy with dopamine agonists or precursors is either of limited efficacy and/or precipitates psychosis or other severe behavioral changes.
As noted above, NMS may require avoiding antipsychotic medication and favor the use of ECT. ECT does not cause NMS and has been shown to be a rapid and effective treatment for NMS.
Additional Note: ECT Treatment Over Objection
See OMH Guidance Statement on ECT Over Objection