Electroconvulsive Therapy - Guidelines For Treatment

Guidelines For Treatment

Experts disagree on whether ECT is an appropriate first-line treatment or if it should be reserved for patients who have not responded to other interventions such as medication and psychotherapy.

The American Psychiatric Association (APA) 2001 guidelines give the primary indications for ECT among patients with depression as a lack of response to, or intolerance of, antidepressant medications; a good response to previous ECT; and the need for a rapid and definitive response (e.g. because of psychosis or a risk of suicide). The decision to use ECT depends on several factors, including the severity and chronicity of the depression, the likelihood that alternative treatments would be effective, the patient's preference and capacity to consent, and a weighing of the risks and benefits.

Some guidelines recommend cognitive behavioral therapy or other psychotherapy before ECT is used. However, treatment resistance is widely defined as lack of therapeutic response to two antidepressants at adequate doses for an adequate duration and with good compliance. The APA states that at times patients will prefer to receive ECT over alternative treatments, but commonly the opposite will be the case.

The APA ECT guidelines state that severe major depression with psychotic features, manic delirium, or catatonia are conditions where there is a clear consensus favoring early ECT. The UK's National Institute for Health and Clinical Excellence (NICE) guidelines recommend ECT for patients with severe depression, catatonia, or prolonged or severe mania. It did not recommend the use of ECT as a maintenace therapy in depressive illness as "the long-term benefits and risks ... had not been clearly established". Due to a lack of data, The NICE Guidelines for the Treatment and Management of Adult Depression (2009) issued no updated treatment recommendation for the use of maintenance or relapse prevention ECT. The 2001 APA guidelines support the use of ECT for relapse prevention.

The 2001 APA ECT guidelines say that ECT is rarely used as a first-line treatment for schizophrenia, but is considered after unsuccessful treatment with antipsychotic medication, and may also be considered in the treatment of patients with schizoaffective or schizophreniform disorder. The 2003 NICE ECT guidelines do not recommend ECT for schizophrenia, and this has been supported by meta-analytic evidence showing no or little benefit versus placebo, or in combination with antipsychotic drugs, including Clozapine.

The NICE 2003 guidelines state that doctors should be particularly cautious when considering ECT treatment for women who are pregnant and for older or younger people, because they may be at higher risk of complications with ECT. The 2001 APA ECT guidelines say that ECT may be safer than alternative treatments in the infirm elderly and during pregnancy, and the 2000 APA depression guidelines stated that the literature supports the safety for mother and fetus, as well as the efficacy during pregnancy.