Referring for ECT – Inpatient Psychiatry Today

Author: Daniel Carlat M.D.
Last Updated: 4/1/20

L was a 79 yo woman who was in general a social and quite capable woman who had suffered several episodes of depression over her life. On the day of her admission, her husband woke up and found her in the kitchen wringing her hands, saying “I don’t know what to do…should I have breakfast?” She was unable to make any decisions and said she was a bad person. Once on our unit, she was pleasant superficially but had difficulty leaving her room because she could not make any decision. Everyday was a struggle. She felt that she was going through the motions like a robot, forcing herself to do things. Her mind was usually racing and she was unable to read or watch TV due to poor concentration. She reviewed old memories, citing them as proof that she was somehow defective. For example, she had not been able to attend her daughter’s 8^th birthday many years ago and she felt tremendously guilty about it.

We initially increased her outpatient dose of Zoloft and added aripiprazole and lorazepam. After a week of no response, we switched her to a combination of duloxetine and quetiapine. She did not respond and was referred for ECT. She improved markedly after her third treatment.

Some ECT Basics

ECT works by producing a small electric current which causes a generalized seizure which in turn yields an antidepressant response via unknown mechanisms. The main indications for ECT are severe depression with suicidality, psychotic depression, depression that prevents the patient from functioning adequately, and catatonia.

Melancholic depression may be a specific constellation of symptoms responsive to ECT—recall from chapter (depression) that this is a severe depression with early morning awakening and worse mood in the morning, a lack of mood reactivity, profound anhedonia, guilt, and psychomotor retardation.

ECT is the most effective treatment for depression with a remission rate of between 70-90%. It works rapidly, with the average response beginning after only three treatments (typically over one week). While it’s remarkable effective, the relapse rate is very high unless ECT is continued on a maintenance basis—typically this entails weekly treatments for a couple of weeks, then bi weekly, then monthly. The six month relapse rate is about 60% if ECT is followed by medication treatment and 35-40% if followed by maintenance ECT or with an aggressive regimen of nortriptyline and lithium.

Who is most (and least) likely to respond to ECT?

There is some evidence that the elderly are more likely to respond to ECT than young people. On the other hand, patients with borderline personality disorder are somewhat less likely to respond to ECT.

ECT is used much more often in elderly patients for various reasons, including the fact that such patients often can’t tolerate antidepressant regimens, may not respond as well to psychotherapy, and tend to develop more severe and life-threatening complications of depression. Luckily, ECT is quite safe even in elderly patients with multiple medical problems.

Adverse effects

Headache
Transient nausea from anesthesia
Cognitive side effects
- Acute confusion for 30 minutes after each treatment occurs in most patients.
- Memory loss for events occurring during the treatment period and a few weeks before and after
- Long term memory loss for past events reported by about 25% of patients
- Many patients report improvement in depression-related cognitive impairment

Medications and ECT

Can continue lithium, antidepressants, and antipsychotics
However you should decrease lithium levels a bit because of possibility of increasing adverse cognitive effects. Withhold one or two doses prior to treatment.
Nortriptyline might be the best antidepressant to combine with ECT—at least the one we have the most data on.
Antipsychotics safe in general, but should try to avoid Thorazine because of some evidence of cardiac effects in ECT. So go with higher potency Aps.
Try to decrease or taper off benzos because they can increase the seizure threshold. But you can use a short acting benzo the night before ECT and can even take a sublingual Ativan an hour beforehand.
Withhold evening dose of anticonvulsants.