Electroconvulsive therapy: a review of the literature

Electroconvulsive therapy (ECT) is a procedure that has been used in the treatment of mental illness for over 60 years. Despite its continued use it remains a controversial treatment, with questions concerning its efficacy being raised not only by mental health professionals, but also service users themselves. The following article reviews the current literature on the administration and effectiveness of ECT, highlighting some of the main points of contention in the debate over its use. In providing a balanced review of the literature, this article aims to serve as an information source for nurses and other mental health professionals who may be involved in the administration of ECT and care of the patients receiving treatment.     

The validity of using an electrocutaneous device for pain assessment in patients with cervical radiculopathy

Abstract

The purpose of this study was to evaluate the validity and preference for assessing pain magnitude with electrocutaneous testing (ECT) compared to the visual analogue scale (VAS) and Borg CR10 scale in men and women with cervical radiculopathy of varying sensory phenotypes. An additional purpose was to investigate ECT sensory and pain thresholds in men and women with cervical radiculopathy of varying sensory phenotypes. This is a cross-sectional study of 34 patients with cervical radiculopathy. Scatterplots and linear regression were used to investigate bivariate relationships between ECT, VAS and Borg CR10 methods of pain magnitude measurement as well as ECT sensory and pain thresholds. The use of the ECT pain magnitude matching paradigm for patients with cervical radiculopathy with normal sensory phenotype shows good linear association with arm pain VAS (R²?=?0.39), neck pain VAS (R²?=?0.38), arm pain Borg CR10 scale (R²?=?0.50) and neck pain Borg CR10 scale (R²?=?0.49) suggesting acceptable validity of the procedure. For patients with hypoesthesia and hyperesthesia sensory phenotypes, the ECT pain magnitude matching paradigm does not show adequate linear association with rating scale methods rendering the validity of the procedure as doubtful. ECT for sensory and pain threshold investigation, however, provides a method to objectively assess global sensory function in conjunction with sensory receptor specific bedside examination measures.     

Electroconvulsive therapy for phantom limb pain

Phantom limb pain is common in amputees. Although several treatments are available, a significant number of patients are refractory. Electroconvulsive therapy (ECT), which is usually given to patients with psychiatric disorders such as major depression, has shown efficacy in patients with a variety of pain syndromes occurring along with depression. Two patients are described herein with severe phantom limb pain refractory to multiple therapies, without concurrent psychiatric disorder, who received ECT. Both patients enjoyed substantial pain relief. In one case, phantom pain was still in remission 3.5 years after ECT. It is concluded that phantom limb patients who are refractory to multiple therapies may respond to ECT.     

Evaluation of an electroconvulsive therapy service in a general hospital

There has been much recent literature on the technical parameters of electroconvulsive therapy (ECT) with regard to improving efficacy and minimizing adverse effects, but relatively little on ECT service delivery. This paper will discuss the development and characteristics of an ECT service at a teaching hospital in metropolitan Sydney, New South Wales, Australia. A mixture of qualitative and quantitative methods, including a selective literature review and audit of ECT use were used. The results of the audit were compared with the 2007 revision of the Royal Australian and New Zealand College of Psychiatrists' clinical memorandum on ECT. We discuss issues, such as the optimal site for ECT delivery, ECT mental health nurse coordinator role, credentialing of psychiatrists, registrar supervision, and the development of an ECT committee. A significant finding of the audit was that the majority of patients were treated under the New South Wales Mental Health Act, and voluntary patients were more likely to have a diagnosis of a depressive disorder, whereas involuntary patients were more likely to have a non-mood disorder diagnosis. This study has shown that auditing of ECT practices and services by mental health nurses is essential for quality improvement processes. The audit highlighted areas of service delivery that should be subject to review and evaluation against professional standards.     

Electroconvulsive therapy in patients with cardiac pacemakers and implantable cardioverter defibrillators

Electroconvulsive therapy (ECT) is used to treat major depressive illness, especially in elderly and medically frail patients. Not uncommonly, these patients have cardiac pacemakers or implantable cardioverter defibrillators (ICDs). Only a few case reports in the literature describe the use of ECT in such patients. Herein we review our ECT experience treating 26 pacemaker patients and 3 ICD patients. All patients obtained significant antidepressant benefits with ETC. Only one serious cardiac event occurred, a case of supraventricular tachycardia (SVT) requiring a stay on the cardiac intensive care unit. The SVT resolved and the patient went on to receive further uncomplicated ECT treatments. We conclude from this experience that with proper pre-ECT cardiac and pacemaker/defibrillator assessment, ECT can be safely and effectively administered to patients with an implanted cardiac device.     

Electroconvulsive therapy improves severe pain associated with fibromyalgia

The pathophysiology of fibromyalgia remains unknown. Several reports have recently suggested the novel concept that fibromyalgia is due to the central nervous system becoming hyper-responsive to a peripheral stimulus. The effect of electroconvulsive therapy (ECT) as pain remedication in cases of fibromyalgia without major depressive disorder was studied in a prospective trial lasting three months. All of the patients taking part in the study fulfilled the American College of Rheumatology diagnostic criteria for fibromyalgia. Technetium-99m ethyl cysteinate dimer single photon emission computed tomography was used to assess regional cerebral blood flow (rCBF) before and after a course of ECT. Pain assessment in the patients was undertaken by use of the visual analog scale (VAS) and by evaluation of tender points (TPs). Beck's depression inventory (BDI) was further used to assess depressive mood change in the patients. Our study clearly demonstrated that pain was significantly less severe after ECT, as indicated by the VAS scale for pain and the evaluation of TPs. A further notable observation was that thalamic blood flow was also improved. We conclude that a course of ECT produced notable improvements in both intractable severe pain associated with fibromyalgia and also in terms of thalamic blood flow.     

MULTIDISCIPLINARY PAIN ABSTRACTS: 37

The aim of the present case series was to examine whether changes in regional cerebral blood flow (rCBF) induced by electroconvulsive therapy (ECT) in the thalamus are related to the efficacy of ECT. Four chronic pain patients with complex regional pain syndrome (CRPS) type I (age 33 to 58 years) who had failed to respond to standard pain treatments received a course of ECT. To investigate the possible mechanisms of the analgesic effect of ECT on chronic CRPS type I, the authors measured significant changes in the rCBF of the thalamus using technetium-99 methyl cysteinate dimer single photon emission computed tomography (99mTc ECD SPECT), before and after ECT and compared these values between responders and nonresponders. Two of four patients responded to ECT. 99mTc ECD SPECT showed that the mean contralateral thalamus-to-cerebellum ratio increased 11.5% after ECT compared with the ratio before ECT in the two responders, but remained unchanged in nonresponders. The results from the SPECT suggest that normalization of the balance of rCBF in the thalamus may be related to the analgesic efficacy of the ECT on CRPS type I.     

Electroconvulsive therapy in patients with depression and fibromyalgia

The effect of electroconvulsive therapy (ECT) on depression and other symptoms of fibromyalgia was studied in a prospective 3‐month trial in 13 patients with fibromyalgia and concomitant depression. All the patients met the DSM‐IV diagnostic criteria for Major Depressive Disorder and fulfilled the American College of Rheumatology diagnostic criteria for fibromyalgia. The Montgomery and Åsberg Depression Rating Scale (MADRS) and the clinical global impression scale (CGI) were used to assess the severity of depression and the clinical change of the patients. The fibromyalgia impact questionnaire (FIQ) was used to evaluate the severity of the fibromyalgia symptoms. The intensity of pain was evaluated using a 6‐point scale (0=no pain, 5=very severe pain), and tender point palpation. All assessments were performed at baseline and at follow‐up visits, which took place one week, one month and three months after ECT. There was a significant improvement in depression after ECT according to MADRS. Using CGI, six patients were much or very much improved, while four patients were minimally improved and three patients had no change. There was significant improvement in four out of ten FIQ item scores, “feel good”, “fatigue”, “anxiety” and “depression”. No significant change was found in the FIQ item scores “physical function”, “pain”, “stiffness” and “morning tiredness” or number of tender points and self‐reported pain. We conclude that ECT is a safe and effective treatment for depression in fibromyalgia patients, but has no effect on the pain or other physical symptoms of these patients.     

Use of Electroconvulsive Therapy With Children: An Overview and Case Report

TOPIC. Electroconvulsive therapy (ECT) has become more common in the treatment ofadults with refractory mood disorders and psychotic disorders but it remains one of the least common therapies for mental illness in children. In a small number of child psychiaty cases, symptoms are severe and unresponsive to standard pharmacological and other therapies. With these patients, ECT might be helpful.
PURPOSE. This article provides an overview of ECT, indications for its use and a case report that illustrates the successful use of ECT with an 8-year-old girl with psychotic depression. Implications for multidisciplinary care are discussed, including preparation of the patient and family, assessment of response to ECT, management of adverse effects, preparation for discharge and discharge care.
SOURCES. Existing literature on the use of ECT in adults, adolescents, and children and the clinical experience of providing care to an 8-year-old patient on an acute care inpatient unit.
CONCLUSIONS. Nurses and other healthcare personnel should consider ECT in refractory cases of major depressive disorder, bipolar affective disorder, schizophrenia, and other psychotic disorders.     

Pain thresholds during and after treatment of severe depression with electroconvulsive therapy.

Pain and depression are often associated suggesting that both conditions share a common neurobiological mechanism, which modulate emotional function and processing of noxious information. Pain thresholds are hypothesized to be altered in depressed patients and normalized with the amelioration of depression. The purpose of this study was therefore to determine pain thresholds in patients during and after treatment with electroconvulsive therapy (ECT) of severe depression and in healthy controls. Seventeen depressed patients (Hamilton depression score > 18) and an age and gender matched control group of same size participated in the study. Pain detection and tolerance thresholds to pressure and pain tolerance thresholds to the Cold Pressor Test by exposure to ice-water was measured twice in depressed patients during and after ECT and twice in controls with a similar time interval. While ECT significantly improved Hamilton depression score (from mean 23.9 (SD:5) to mean 12.5 (SD:5.7)) there was no significant change in pain thresholds during and after ECT in the patient group. However, depressed patients had significantly lower pain tolerance in the Cold Pressor Test on both examinations and on pressure pain tolerance on the second examination day than their corresponding control subjects. The differential effect of ECT on depression score and pain processing indicate that mood and noxious processing are not medicated directly by the same systems but that a complex relationship between pain and depression exists.     

Headache and Electroconvulsive Therapy

SYNOPSIS
While headache is a documented side effect of electroconvulsive therapy (ECT), there is little information on this phenomenon. Studies of the mechanisms of ECT as a treatment for depression indicate that alterations in serotonergic neurotransmission appear to be related to its efficacy. While ECT and many of the antidepressant drugs have similar effects on serotonergic transmission, they are notably different in the changes they induce in type 2 receptors for 5-hydroxytryptamine (5-HT). ECT upregulates 5-HT₂, and antidepressants down regulate the receptor's expression. 5-HT₂ receptor sensitization has been associated previously with headache genesis, which may explain why ECT induces headache, and amitriptyline relieves headache.
In our study we surveyed 98 patients retrospectively about their experiences with headache prior to and following ECT. Of the 54 patients who submitted properly completed questionnaires, five reported new onset of headaches following ECT, four reported exacerbation of a previous headache problem, and two reported their headaches improved. The patients experienced changes in the character or location of pain, with a tendency to progress from tension-type to migrainous headache. In all but two cases these developments persisted at least eight months after ECT. We discuss the possible reasons and significance of our findings.     

The influence of electroconvulsive therapy on pain threshold and pain tolerance in major depression patients before, during and after treatment.

Despite the findings that pain and depression are not always directly linked, enough evidence suggest that a complex relationship between pain and depression exists. Using an electronic pressure algometer placed on the sternum, the changes in pressure pain threshold (PPThr) and pressure pain tolerance (PPTol) were evaluated in 19 patients affected by refractory major depression without psychotic features, throughout a full course of electroconvulsive therapy (ECT) treatment. Measurements were done before the first treatment, after the 6th treatment and after the last treatment. After the 6th treatment, mean (+/- SD) PPThr increased significantly from 11.48 (+/- 4.81) kg/cm2 at baseline, to 13.7 (+/- 5.59) kg/cm2 (p=0.0076) while PPTol did not change significantly (from 18.46 (+/- 6.75)kg/cm2 to 17.4 (+/- 8.1)kg/cm2). At the end of the treatment course, mean (+/- SD) PPThr did not increase further significantly (15.06 (+/- 5.21)kg/cm2 (p=0.0234)) while PPTol increased significantly to 21.34 (+/- 7.8)kg/cm2 (p=0.0047). ECT's efficacy was measured with the 21-item Hamilton Rating Scale for Depression (21-HAM-D). Mean (+/- SD) 21-HAM-D scores decreased significantly from 30.9 (+/- 4.15) at baseline, to 10.47 (+/- 5.78) (p=0.0001) after the 6th treatment, with no further significant change at the end of the treatment course (9.94 +/- 3.07; p=0.0254). Both pain threshold and pain tolerance increased following the alleviation of the depressive disorder and a possible usefulness of ECT may be postulated for treating severe, chronic pain syndromes. However, a more significant conclusion is that the increase of the PPThr noted early during ECT treatment may serve as an early outcome possible detector of ECT efficacy in depressed patients.     

Thalamic pain--the effect of electroconvulsive therapy (ECT)

An open study of the effect of a standard course of unilateral ECT applied to 4 patients with intractable thalamic pain. There was no significant change in pain, personality or affective profiles after treatment. Venous plasma endorphins were measured during the ECT course and there were no significant correlations with treatment.     

ECT in the treatment of recurrent psychotic depression.

Two cases of recurrent psychotic depression are reported in which ECT (electroconvulsive therapy) was administered with good results for previous episodes of depression, but treatment of the current episode with combined drug therapy (antidepressant and antipsychotic drugs) in one case and antidepressant chemotherapy in the other resulted in failure to improve. The patients were transferred to another facility, and improved when ECT was administered. Pertinent literature on ECT and drug treatment of depression is reviewed, and the conditions for which ECT is probably the treatment of choice are enumerated.     

AANA Journal course: update for nurse anesthetists--anesthetic management during electroconvulsive therapy: effects on seizure duration and antidepressant efficacy.

Electroconvulsive therapy (ECT) is an effective treatment for some types of depression and psychotic disorders. Although ECT is considered effective and relatively safe, the treatment team must know how to deal with adverse effects. The American Psychiatric Association recognizes no absolute contraindication except brain tumor with increased intracranial pressure. However, patients who have other medical problems are at risk of complications. Optimizing the safety and efficacy of treatment is a goal when providing ECT. Muscle relaxants, barbiturate anesthesia, anticholinergic agents, and oxygenation are used to reduce the risk of complications. The use of ECT requires a knowledge of the effect of anesthetic agents on seizure activity. This article reviews ECT, anesthesia for ECT, and the effect of propofol and methohexital on seizure duration and seizure efficacy.     

Bilateral Open Thoracic Cordotomy for Refractory Cancer Pain: A Neglected Technique?

At least 10% of patients with cancer have pain that is refractory to systemic analgesics. For most of these patients, interventional techniques may be of benefit but are often not considered or are difficult to access. Of these techniques, spinal analgesia is most commonly used in Australia and the United Kingdom, and neurosurgical procedures, such as open cordotomy with sectioning of the spinothalamic tract, are rarely used. We describe a case illustrating the successful use of bilateral open thoracic cordotomy in a patient with refractory mixed nociceptive and neuropathic pain secondary to a lumbosacral tumor. We discuss the various interventional options and review the recent literature regarding the use of both percutaneous and open cordotomy for cancer pain.     

Anesthetic considerations for electroconvulsive therapy.

Electrically induced seizures have been used widely to treat psychiatric disease since their introduction in 1938. Seizure activity is the therapeutic aspect of this form of treatment, but it is accompanied by untoward physiologic consequences. Cardiovascular responses consist of generalized autonomic nervous system stimulation with initial parasympathetic outflow, followed immediately by a sympathetic response. In certain patients the sequence described may result in an initial bradycardia or even asystole, followed by tachycardia, dysrhythmia, and hypertension. The cerebrovascular system responds with a marked increase in cerebral blood flow in response to increased cerebral oxygen consumption, and dramatic elevation of intracranial pressure. General anesthesia for electroconvulsive therapy (ECT) must be administered only in locations equipped for support of the unconscious patient and treatment of complications. Intravenous access is mandatory in all patients, as is monitoring of blood pressure, and ECG, as well as pulse oximetry. Appropriate oxygen supplementation and ventilatory support are essential as they are during any procedure necessitating general anesthesia. Methohexital, 0.75 to 1.0 mg/kg intravenously, is the most frequently used agent for induction of anesthesia for ECT; muscle relaxation usually is accomplished with succinylcholine, 0.5 to 1.0 mg/kg. In patients at risk for ill effects from the tachycardia and hypertension that may accompany sympathetic nervous system response to ECT, nitroglycerin, propranolol, hydralazine, or other sympatholytic agents should be used to attenuate the potentially harmful sequelae of ECT. The efficacy of ECT requires a knowledge of anesthetic precepts, an understanding of the interaction between anesthetic drugs and seizure activity, and an awareness of the physiologic effects of ECT as well as the treatment of those effects.     

Opioid treatment of chronic pain in patients with addiction

Patients with a history of drug or alcohol addiction may present to physicians with pain complaints. The medical literature is weak on the treatment of pain with opioids in patients in recovery or active addiction. This is because inconsistent criteria were used to define addiction and the types of chronic pain. There are clear differences between physical dependence, tolerance, and addiction. Addiction is different from pseudoaddiction and must be determined by the patient's behavior after appropriate pain management. Long-acting opioids are often the medications of choice for moderate to severe pain control. Short-acting opioids can be used for breakthrough pain. There are many other medications that can enhance pain control as adjunctive analgesics. Drug-seeking behavior may be seen with either active addiction or pseudoaddiction, or as part of deviant behavior such as drug diversion. A way to distinguish between these conditions is by giving the patient appropriate pain medication and observing the pattern of behavior to determine which is causing the drug-seeking behavior. Safe prescribing of medications with abuse potential includes use of a medication agreement, setting goals with the patient, giving appropriate amounts of pain medication, monitoring with pill counts and drug screens, and careful documentation. Even patients with a history of addiction can benefit from opioid pain medications if monitored appropriately.     

Electroconvulsive therapy and/or plasmapheresis in autoimmune encephalitis?

Autoimmune encephalitis is a poorly understood condition that can present with a combination of neurological and psychiatric symptoms, either of which may predominate. There are many autoantibodies associated with a variety of clinical syndromes - anti-N-Methyl-D-Aspartate receptor (NMDAR) is the commonest. Currently, the most widely used therapy is prompt plasmapheresis and steroid treatment (and tumour resection if indicated), followed by second line immunosuppression if this fails. Given the growing awareness of autoimmune encephalitis as an entity, it is increasingly important that we consider it as a potential diagnosis in order to provide timely, effective treatment. We discuss several previously published case reports and one new case. These reports examined the effects of electroconvulsive therapy (ECT) on patients with autoimmune encephalitis, particularly those in whom psychiatric symptoms are especially debilitating and refractory to standard treatment. We also discuss factors predicting good outcome and possible mechanisms by which ECT may be effective. Numerous cases, such as those presented by Wingfield, Tsutsui, Florance, Sansing, Braakman and Matsumoto, demonstrate effective use of ECT in anti-NMDAR encephalitis patients with severe psychiatric symptoms such as catatonia, psychosis, narcolepsy and stupor who had failed to respond to standard treatments alone. We also present a new case of a 71-year-old female who presented to a psychiatric unit initially with depression, which escalated to catatonia, delusions, nihilism and auditory hallucinations. After anti-NMDAR antibodies were isolated, she was treated by the neurology team with plasmapheresis and steroids, with a partial response. She received multiple sessions of ECT and her psychiatric symptoms completely resolved and she returned to her premorbid state. For this reason, we suggest that ECT should be considered, particularly in those patients who are non-responders to standard therapies.