Electroconvulsive therapy in the treatment of depression in elderly

The use of a electroconvulsive therapy (ECT) in the elderly suffering from depression is still controversial in Poland. Not only psychiatrists but also specialists who qualify the patients for ECT--internal medicine specialists, neurologists and anaesthesiologists--treat the advanced age of a patient as a contraindication to ECT. It is also believed that ECT has adverse influence on the mental state of patients with the so-called psychoorganic syndrome. In most centres in Poland ECT is reserved for patients with drug-resistant depression and those in whom pharmacotherapy is contraindicated for any reason, such as pregnancy. Nevertheless the patients are carefully selected with respect to their physical condition. In many countries however the older the patient, the more likely he/she is to receive ECT as a method of choice. The effectiveness of this method in elderly patients is considered to be higher than in younger groups. ECT seems to be particularly effective in depression with psychotic symptoms and psychomotor retardation. The adverse effect of ECT on cognitive functions (learning and memory) which is a great concern of both doctors and patients, is actually noted in a small group of patients and usually transient. Moreover, the frequency of occurrence of this effect in elderly is not greater than in younger patients.     

Electroconvulsive therapy in depression

Electroconvulsive therapy (ECT) has been in use for over 50 years and remains one of the most effective treatments in psychiatry. Effectiveness rates for ECT in depression range between 80% and 90%; no comparative study has shown any other intervention to be superior to ECT. ECT is also recommended for mania, schizophrenia and as a safe treatment for the elderly or medically ill depressed patient. This paper will deal with the use of ECT in depression. The areas to be covered are the clinical indications, the factors predictive of response, the evidence for the efficacy of ECT, as well as theories of the mechanism of its action, side effects and guidelines for prescribing the procedure. Notwithstanding the efficacy, the safety and perhaps an improved public acceptance, some observers have noted that there is a decline in the use of ECT. Others have suggested that such a decline may be evident only in the public sectors such as state and provincial psychiatric hospitals. Ongoing research is necessary to achieve further refinement of ECT, as well as enhance our understanding of this important treatment procedure.     

Electroconvulsive therapy use in geriatric depression

A retrospective review of elderly patients who received electroconvulsive therapy (ECT) over an 18-month period found ECT to be safe and effective. Of the 1159 patients admitted to the psychiatric unit during this time period, 50 patients (4.3%) aged 61 to 88 received between two and 14 ECT treatments. Brief pulse current with bilateral electrode placement and electroencephalogram monitoring were used with each patient. A total of 46 patients (92%) were much improved after ECT. Of the four nonresponders, three terminated treatment prematurely due to increased confusion, and one failed to respond after a course of 12 ECT treatments. There were no medical complications related to the ECT. A mean of 4.93 months from the onset of symptoms until receiving ECT may be one factor in our better outcome compared to some recent studies where treatment was delayed. The exclusive use of brief pulse current and its resultant lower level of confusion also may be important.     

Electroconvulsive therapy for poststroke depression

Of the 193 patients with stroke and depression treated at Massachusetts General Hospital from 1969 to 1981, 14 had electroconvulsive therapy (ECT) for poststroke depression. Among these 14 patients, depression developed less than 1 year after stroke in 9 and more than 1 year after stroke in 5. Except for 2 of the patients in whom depression developed within a year, all had marked improvement in depression after ECT. A transitory cardiac arrhythmia developed in 1 patient, but none of the patients had an exacerbation of stroke or a worsening of neurologic status. These findings indicate that ECT is safe and effective for poststroke depression.     

The impact of coexisting depression and timing of psychiatric consultation on medical patients' length of stay

Patients with a psychiatric disorder are known to make greater use of medical resources than patients without a psychiatric condition, but the impact of highly prevalent psychiatric illnesses, such as depression, on use of medical resources has not been fully explored. This study assessed the lengths of stay of 92 medical and surgical patients who met DSM-III criteria for depression and the relationship of their length of stay to the timing of psychiatric consultations. The 92 patients were hospitalized significantly longer (a mean of 2.52 days more) than they would have been had their length of stay been determined by their medical diagnosis-related group (DRG). A subgroup of 38 Medicare patients were hospitalized a mean of 5.22 days more than the mean stay allowed by their DRG. Consultations occurring earlier in the hospitalizations were linked to shorter stays.     

Electroconvulsive therapy and cognitive functions in treatment-resistant depression

Objectives. Electroconvulsive therapy (ECT) is the most effective treatment for drug-resistant depression (DRD). We estimated the short- and long-term effects of ECT on cognitive functions in patients with unipolar and bipolar DRD. Methods. We investigated 63 patients (18 male, 45 female), aged 34–75 years. Cognitive assessments were performed before, immediately after 6–12 ECT sessions, and 3 months thereafter, using the Benton Visual Retention, Trail Making (TMT), Rey-Osterrieth Complex Figure (ROCF) tests, the Digit Span of the Wechsler Adult Intelligence Scale, and the Rey Auditory Verbal Learning (RAVLT), verbal fluency and Stroop tests. Results. Immediately after ECT, a significant worsening was noted in some indices of memory and verbal fluency. However, 3 months after ECT, the indices of both RAVLT and verbal fluency significantly improved compared to baseline, and those of the Benton and ROCF were significantly better than before ECT. The Digit Span, Stroop and TMT were not affected by the treatment. Conclusions. The negative effects of ECT on the reported measures of cognition are transient. After 3 months, the indices of memory were significantly better than before the treatment. In addition to its antidepressant effect in DRD, ECT may also exert a long-term favourable influence on some cognitive functions.     

Electroconvulsive therapy for treatment of refractory depression in a patient with cystic fibrosis

Cystic fibrosis (CF) is an autosomal recessive inherited disease that is usually first diagnosed in early childhood. It is a chronic and progressive disease in which mucus builds up and clogs passages in many body organs, but primarily the lungs and pancreas. We present a case report of a 42-year-old man with CF who was treated with electroconvulsive therapy for treatment-refractory major depressive disorder. For patients with CF, the primary issue is anesthetic management in a patient with impaired pulmonary function. Our patient received prednisone and intravenous antibiotics to optimize pulmonary status. He responded positively to the electroconvulsive therapy and was able to tolerate it without significant problems.     

Electroconvulsive therapy and major depression in Down's syndrome

The authors treated two patients who had Down's syndrome and major depression with a combination of inpatient and outpatient electroconvulsive therapy (ECT). They found only 10 other similar published cases, although none involved outpatient ECT. Their experience, in conjunction with that reported in the literature, indicates that ECT is a safe and effective treatment for depressed mentally retarded individuals, including those who respond poorly to antidepressants.     

Electroconvulsive therapy for depression in general psychiatric practice

This paper identifies areas of consensus about the use of electroconvulsive therapy (ECT) for depression and some of the important points of disagreement which have implications for clinical practice and research. The clinical indications for ECT as a primary treatment of choice, a secondary treatment, and a maintenance or prophylactic treatment for depression are described. The commonly accepted outcome findings that ECT is highly effective are contrasted with more recent data indicating it may be quite ineffective when administered with a low-dose electric stimulus. The constituents of the treatment dosage are presented in the context of controversy surrounding the respective contributions of the electrical energy of the stimulus and the convulsions themselves to the overall therapeutic effectiveness. The points of consensus within the limited knowledge in this area are identified as the basis for the most appropriate approach to the design of clinical dosage protocols. It is concluded that ECT is an effective treatment for some of the severe presentations of depression. Its therapeutic effectiveness should not be compromised by efforts to minimize the side effects through excessive dosage reduction.     

Electroconvulsive therapy treatment of depression in a patient with adult GM2 gangliosidosis.

Adult GM2 gangliosidosis is a rare disorder that often presents with both neurological and psychiatric syndromes. Effective treatment of the psychotic and affective symptoms associated with this disorder has been complicated by poor treatment response and the concern that many psychotropic agents may worsen the underlying gangliosidosis. We report the successful use of electroconvulsive therapy for treatment of severe depression in a young man with adult GM2 gangliosidosis.     

Electroconvulsive therapy for major depression in borderline personality disorder

Depressive disorder is a serious and frequent complication in borderline personality disorder (BPD), however, its severity tends to be neglected particularly if symptoms are short-lived or inconsistent as is common in patients with BPD. Yet the high frequency in these patients requires especially rapid and effective therapy to reduce the risks of vital endangerment, chronification and psychosocial impairment. Efficient crisis intervention is essential for continuity of the disease-specific multimodal therapy enabling lasting remission and social and vocational rehabilitation in BPD. In particular with regard to the high incidence of poor or failed pharmacological responses in patients with BPD, electroconvulsive therapy (ECT) is of significant relevance among antidepressant treatment options. Despite the wide consensus on its efficacy, there are only few selected trials on ECT for major depression (MD) in BPD. This review summarises the published original studies on this issue, and critically scrutinises indication, benefits and risks of ECT for MD in BPD. It contributes to a focused, discriminating view on ECT and thus enables an optimised patient-oriented, efficient indication for MD in BPD.     

Electroconvulsive therapy in patient with psychotic depression and multiple sclerosis

Safety of electroconvulsive therapy (ECT) in depressive patients with multiple sclerosis (MS) is still discussed and based solely on case reports. This kind of therapy was used in both unipolar depression and depression in bipolar disorder. It was suggested that ECT might cause the deterioration of neurological state (new MS lesions in magnetic resonance imaging). Moreover, there were also data indicating some anesthesiological complications and difficulties in patients with MS. We have presented a case of a patient who was treated with ECT and developed grand mal seizure after 14th electroconvulsive treatment.     

Electroconvulsive therapy is equally effective in unipolar and bipolar depression

Bailine S, Fink M, Knapp R, Petrides G, Husain MM, Rasmussen K, Sampson S, Mueller M, McClintock SM, Tobias KG, Kellner CH. Electroconvulsive therapy is equally effective in unipolar and bipolar depression. Objective: To determine the relative efficacy of electroconvulsive therapy (ECT) in the treatment of bipolar (BP) and unipolar (UP) depressive illness and clarify its role in BP depression. Method: Patients referred for ECT with both UP and BP depressions. [classified by Structured Clinical Interview for DSM (SCID‐I) criteria for history of mania] were included in a multi‐site collaborative, double‐masked, randomized controlled trial of three electrode placements – right unilateral, bifrontal or bitemporal – in a permutated block randomization scheme. Results: Of 220 patients, 170 patients (77.3%) were classified as UP and 50 (22.7%) as BP depression in the intent‐to‐treat sample. The remission and response rates and numbers of ECT for both groups were equivalent. Conclusion: Both UP and BP depressions remit with ECT. Polarity is not a factor in the response rate. In this sample ECT did not precipitate mania in depressed patients. Treatment algorithms for UP and BP depression warrant re‐evaluation.     

Electroconvulsive therapy for the treatment of refractory mania

We present the case of a patient with treatment-refractory mania. The patient had been tried on numerous medications, to which she either did not respond well or on which she developed severe side effects, However, the patient improved rapidly when treated with unilateral electropercussive therapy (ECT) following a court order. We outline the legal barriers that have been raised against the use of ECT in patients with mania, who often refuse treatment, and the irony that ECT can be safer than medications for some patients. ECT is underutilized in mania but deserves more frequent consideration. (Journal of Psychiatric Practice. 2011;17:61-66).     

Electroconvulsive therapy mediates neuroplasticity of white matter microstructure in major depression

Whether plasticity of white matter (WM) microstructure relates to therapeutic response in major depressive disorder (MDD) remains uncertain. We examined diffusion tensor imaging (DTI) correlates of WM structural connectivity in patients receiving electroconvulsive therapy (ECT), a rapidly acting treatment for severe MDD. Tract-Based Spatial Statistics (TBSS) applied to DTI data (61 directions, 2.5 mm³ voxel size) targeted voxel-level changes in fractional anisotropy (FA), and radial (RD), axial (AD) and mean diffusivity (MD) in major WM pathways in MDD patients (n=20, mean age: 41.15 years, 10.32 s.d.) scanned before ECT, after their second ECT and at transition to maintenance therapy. Comparisons made at baseline with demographically similar controls (n=28, mean age: 39.42 years, 12.20 s.d.) established effects of diagnosis. Controls were imaged twice to estimate scanning-related variance. Patients showed significant increases of FA in dorsal fronto-limbic circuits encompassing the anterior cingulum, forceps minor and left superior longitudinal fasciculus between baseline and transition to maintenance therapy (P<0.05, corrected). Decreases in RD and MD were observed in overlapping regions and the anterior thalamic radiation (P<0.05, corrected). Changes in DTI metrics associated with therapeutic response in tracts showing significant ECT effects differed between patients and controls. All measures remained stable across time in controls. Altered WM microstructure in pathways connecting frontal and limbic areas occur in MDD, are modulated by ECT and relate to therapeutic response. Increased FA together with decreased MD and RD, which trend towards normative values with treatment, suggest increased fiber integrity in dorsal fronto-limbic pathways involved in mood regulation.